N.Y. Comp. Codes R. & Regs. tit. 14, § 635-10.5
(1) Definitions applicable to this subdivision.
(iv) Qualified service coordinator. Someone who meets the requirements of either clause (a) or (b) of this subparagraph:
(a) he or she:
(2) attends:
(b) he or she:
(4) attends:
(2) Reimbursement eligibility.
(ii) In order for the service to be reimbursable, the person receiving the service shall:
(a) meet the requirements of either subclause (1) or (2) of this clause as follows:
(3) Method of reimbursement and payment.
(4) Initial PCSS.
(iii) A provider shall only be paid for initial PCSS once for an individual. If a provider provides PCSS described in paragraph (3) of this subdivision in the same month during which it provides initial PCSS, the provider shall only be paid for initial PCSS.
(b) Residential habilitation services.
(3) Reimbursement for residential habilitation services provided in non-state operated IRAs and CRs on or after July 1, 2014 shall be in accordance with the provisions of Subpart 641-1 of this Title. Subpart 641-1 supersedes the provisions of this subdivision for reimbursement of residential habilitation services provided in non-state operated supervised and supportive IRAs and CRs on or after July 1, 2014, except those provisions pertaining to enrollment and service days in paragraphs (9) - (13) of this subdivision.
Note:
Subpart 641-1 includes a provision that changes the unit of service for residential habilitation services provided in non-state operated supervised IRAs and CRs from a monthly to a daily unit of service (See paragraphs [9] and [13] of this subdivision).
(7) An annual price period is a 12-month period as follows:
(9) Supervised IRA residential habilitation (supervised IRA RH).
(iii) A monthly supervised IRA price will be effective for residential habilitation services delivered in a provider's supervised IRAs and supervised community residences that have:
(iv) Effective January 1, 2010, the IRA operating and capital reimbursement shall be consolidated with the community residence operating and capital reimbursement and the IRA price shall be calculated as follows:
(v) Countable service days.
(vii) Effective January 1, 2011, capital moveable equipment and property insurance shall become fixed values contained in the cost category other than personal services.
(10) Monthly supportive IRA price.
(ii) A monthly supportive IRA price will be effective for residential habilitation services delivered in a provider's supportive IRAs and supportive community residences that have:
(iii) Effective January 1, 2010, the IRA operating and capital reimbursement shall be consolidated with the community residence operating and capital reimbursement and the IRA price shall be calculated as follows:
(iv) Countable service days.
(vi) Effective January 1, 2011, capital moveable equipment and property insurance shall become fixed values contained in the cost category other than personal services.
(11) Enrollment requirements for individuals enrolled in a supervised or supportive IRA.
(12) Standards for service days.
(i) Supervised IRA RH service days, effective July 1, 2014, require:
(a) the individual's presence at the supervised IRA, or one of the following allowable exceptions:
(iii) Countable service days prior to July 1, 2014:
(c) For supervised IRAs only: in determining countable service days the provider may include days when an individual is away from the IRA, for purposes such as vacations and visits with family or friends, only when staff from the individual's IRA deliver and document services to that individual that are similar in scope, frequency and duration to the residential habilitation services typically delivered to the individual at the IRA.
(d) The provisions of this paragraph notwithstanding, days when all residents of the IRA are relocated due to an emergency or other conditions that necessitate relocation for the health and safety of the residents may be considered as countable if:
(18) Determination of the efficiency adjustment for individualized residential alternatives (IRAs):
(i) Effective January 1, 2003, there shall be an efficiency adjustment for IRAs as follows:
(b) The efficiency adjustment described herein will not apply to:
(f) Within each region, the providers' allowed IRA administration operating reimbursements per individual are ranked in descending order. The rankings are grouped into five groups, beginning with Group 5 which contains the providers with the highest administration operating reimbursement per individual and continuing on to Group 1 which contains the providers with the lowest administration operating reimbursement per individual. Each such group represents one fifth of the providers in the region. The dollar ranges in administration operating reimbursement per individual that determine a provider's placement in a group are shown in the following table:
| Region | Group 5 | Group 4 | Group 3 | Group 2 | Group 1 |
|---|---|---|---|---|---|
| I | $11,974+ | $11,973-$10,947 | $10,946-$9,698 | $9,697-$8,061 | $8,060-0 |
| II | $11,677+ | $11,676-$9,238 | $9,237-$7,707 | $7,706-$6,830 | $6,829-0 |
| III | $10,404+ | $10,403-$8,800 | $8,799-$7,488 | $7,487-$6,059 | +$6,058-0 |
(g) The following chart indicates the percentage reduction to allowed IRA administration operating reimbursements for each group in each region:
| Region | Group 5 | Group 4 | Group 3 | Group 2 | Group 1 |
|---|---|---|---|---|---|
| I | 4.285% | 3.428% | 2.571% | 1.714% | 0.0% |
| II | 5.435% | 4.348% | 3.261% | 2.174% | 0.0% |
| III | 5.310% | 4.248% | 3.186% | 2.124% | 0.0% |
(ii) Effective October 1, 2010, for providers in all regions there shall be an efficiency adjustment applied to the IRA price for the residential habilitation services provided in supervised IRAs and supervised community residences.
(a) There shall be three components of the efficiency adjustment as follows:
(1) Non-personal Services (NPS). Providers which demonstrate a level of NPS at or above the benchmark described in item (ii) of this subclause shall be subject to a reduction in the supervised IRA price.
(2) Administration. Providers which demonstrate a level of administration contained in the supervised IRA price at or above the benchmark described in item (ii) of this subclause shall be subject to a reduction in the supervised IRA price.
(3) Residual adjustment. For providers subject to either one or both of the reductions described in subclauses (1) and (2) of this clause, a residual adjustment shall be implemented as described in items (i) and (ii) of this subclause. The residual adjustment shall confine the aggregate effect of this efficiency adjustment and an offset factor of $44 per unit of service to a range between a minimum of 1.5 percent and a maximum of 3.5 percent of the total supervised IRA price on October 1, 2010.
(iv) Effective July 1, 2011, supervised IRA prices shall be reduced according to the measures outlined in this subparagraph. There are two distinct actions to the price reductions. The personal services action addresses provider surpluses in funding for direct care, clinical and support staff and the associated fringe benefits. The administrative action addresses reimbursable administrative costs and holds reimbursement to a level of efficiency. Providers may be subject to only one action or to both actions or they may be exempt from both.
(b) Personal services surpluses action.
(1) Exemptions.
(B) Fringe benefit percentage. The fringe benefit percentage equals the total fringe benefits costs for direct care, clinical and support staff divided by the salary costs for direct care, clinical and support staff expressed as a percentage. For the providers which meet the criterion in subitem (A) of this item, OPWDD compared each provider's actual direct care, clinical and support services associated fringe benefit percentage as evidenced by its 2008/2008-2009 cost report data to the reimbursable direct care, clinical and support services associated fringe benefit percentage as reflected in the corresponding price(s). OPWDD identified a subset of providers with actual fringe benefit percentages that were higher than the fringe benefit percentage in the price(s). They are exempt.
(c) Administrative action.
(1) Exemptions.
(3) Tentative aggregate gross reduction. For providers subject to the administrative action, OPWDD used the compensation data also used in item (1)(ii) of this clause and the reported number of FTEs corresponding to those administrative titles as reported in providers' 2008/2008-2009 cost reports. OPWDD computed a provider-specific average compensation per FTE for the administrative titles. Similarly, OPWDD computed a provider-specific average compensation per FTE for direct care, clinical and support staff using data from providers' 2008/2008-2009 cost reports. (Direct care, clinical and support staff collectively are referred to as direct support staff.) The compensation data for both administrative titles and direct support titles included fringe benefits. A ratio of average administrative compensation to average direct support compensation was determined for each provider. Providers' ratios were then ranked and separated into 5 graduated levels. A reduction percentage was established to correspond to each level of compensation ratios. The reduction percentage for a provider is dependent on a provider's positioning in the five levels. The following chart gives the explicit ranges for the compensation ratios and the applicable reduction percentage. The tentative aggregate gross reduction equals the reduction percentage determined by a provider's ranking in the compensation ratio comparisons applied to that provider's aggregate reimbursable administrative costs as reflected in the corresponding price(s) at June 30, 2011.
| Compensation Ratios | Reimbursable Administrative Costs |
| Administration to Direct Support | Reduction Percentage |
| Equal to or greater than 10.0:1 | 9.0% |
| Equal to or greater than 6.0:1 but less than 10.0:1 | 7.5% |
| Equal to or greater than 4.0:1 but less than 6.0:1 | 6.0% |
| Equal to or greater than 3.0:1 but less than 4.0:1 | 4.0% |
| Less than 3.0:1 | 2.0% |
(19) At home residential habilitation (AHRH) services. Only paragraphs (15), (17) and (19)-(21) of this subdivision shall apply to AHRH services which were provided on or after February 1, 2009 and prior to November 1, 2010. Effective November 1, 2010, providers which were authorized to provide AHRH services immediately prior to that date are authorized to provide community habilitation services (see subdivision [ab] of this section).
(ix) Billable service time is time when staff are providing face-to-face AHRH services to an individual in accordance with the individual’s AHRH Plan. Time spent receiving another Medicaid service cannot be counted toward the AHRH billable service time, except as follows:
(e) AHRH may be billed when the AHRH staff is with the individual at an appointment for a clinical service of the type specified in this clause in order to facilitate the implementation of therapeutic methods and treatments in the home. The time when an individual is being transported to and from the appointment may also be counted as long as the staff accompanies the individual and Medicaid is not being charged for a transportation attendant for the trip.
(20) AHRH which is self-directed or family-directed. The following requirements apply to AHRH services which are self-directed or family-directed and which are provided on or after February 1, 2009 and prior to November 1, 2010, and are in addition to the provisions of paragraph (19) of this subdivision.
(iii) AHRH services which are self-directed are available when all parties to the co-management agreement concur that the individual receiving the AHRH services:
(b) is an adult who:
(c) is a minor and there is an identified adult who is either:
(vi) The following responsibilities (except as noted in subparagraph [vii] of this paragraph) shall be the individual’s and/or the identified adult’s:
(viii) The provider’s responsibilities shall include:
(21) AHRH fee setting. The following applies to the reimbursement of AHRH services provided on or after February 1, 2009. Reimbursement for AHRH services is not available for services provided on or after November 1, 2010. However, OPWDD may continue to effectuate fee reductions on or after November 1, 2010 for services delivered prior to such date in accordance with the provisions of clause (ii)(c) of this paragraph.
(i) Hourly fee schedule structure. Hourly fees are based on the following:
(a) The region in which the service is delivered - region I, region II or region III.
(ii) Transitional hourly fees - 2009 and 2010. Providers may be eligible to receive a transitional hourly fee for AHRH - Individual or AHRH - Group during a 23-month phase-in period. For the period beginning February 1, 2009 and ending December 31, 2009, for each region, there will be the standard hourly fee and there will be level I and level II transitional hourly fees. In 2010, for each region, there will be the standard hourly fee and there will be a level I transitional hourly fee. OPWDD shall determine a provider’s eligibility for the transitional hourly fee(s) based on its examination of the provider’s costs relative to an estimate of the service hours delivered.
(c) If data obtained subsequent to OPWDD’s determination of a provider’s eligibility for a transitional hourly fee does not support that determination, OPWDD may reduce the provider’s fee from the level II transitional hourly fee to the level I transitional hourly fee or from a transitional hourly fee to the standard hourly fee, retroactive to the date as of which the provider received the transitional hourly fee.
(iii) Fee schedules:
(a) Fee schedules effective February 1, 2009.
(1) AHRH/Direct Support—Individual—Fee is hourly.
| Standard Regional Fee | Level 1 Transitional Fee | Level II Transitional Fee | |
| Region I | $36.50 | $43.75 | $59.89 |
| Region II | $37.50 | $60.39 | $68.32 |
| Region III | $36.50 | $50.68 | $67.11 |
(2) AHRH/Direct Support—Group services—Fee is hourly per person.
(i) Group Standard Regional Fees
| Serving 2 Individuals | Serving 3 Individuals | Serving 4 or more Individuals | |
| Region I | $22.81 | $18.25 | $15.97 |
| Region II | $23.44 | $18.75 | $16.41 |
| Region III | $22.81 | $18.25 | $15.97 |
(ii) Group Level I Transitional Fees
| Serving 2 Individuals | Serving 3 Individuals | Serving 4 or more Individuals | |
| Region I | $27.34 | $21.88 | $19.14 |
| Region II | $37.74 | $30.20 | $26.42 |
| Region III | $31.68 | $25.34 | $22.17 |
(iii) Group Level II Transitional Fees
| Serving 2 Individuals | Serving 3 Individuals | Serving 4 or more Individuals | |
| Region I | $37.43 | $29.95 | $26.20 |
| Region II | $42.70 | $34.16 | $29.89 |
| Region III | $41.94 | $33.56 | $29.36 |
(b) Fee schedules effective November 1, 2009. The hourly AHRH fees shall incorporate health care adjustments IV and V funding equivalent to a 1.0 percent increase in the applicable standard regional fee for each of the adjustments. Increases for HCA IV and HCA V shall be applied sequentially to effect compounding of the adjustments.
(1) AHRH Direct Support—Individual—Fee is hourly.
| Standard Regional Fee | Level I Transitional Fee | Level II Transitional Fee | |
| Region I | $37.23 | $44.48 | $60.62 |
| Region II | $38.25 | $61.14 | $69.07 |
| Region III | $37.23 | $51.41 | $67.84 |
(2) AHRH Direct Support—Group services—Fee is hourly per person.
(i) Group Standard Regional Fees
| Serving 2 Individuals | Serving 3 Individuals | Serving 4 or more Individuals | |
| Region I | $23.27 | $18.62 | $16.29 |
| Region II | $23.91 | $19.13 | $16.74 |
| Region III | $23.27 | $18.62 | $16.29 |
(ii) Group Level I Transitional Fees
| Serving 2 Individuals | Serving 3 Individuals | Serving 4 or more Individuals | |
| Region I | $27.80 | $22.25 | $19.46 |
| Region II | $38.21 | $30.58 | $26.75 |
| Region III | $32.14 | $25.71 | $22.49 |
(iii) Group Level II Transitional Fees
| Serving 2 Individuals | Serving 3 Individuals | Serving 4 or more Individuals | |
| Region I | $37.89 | $30.32 | $26.52 |
| Region II | $43.17 | $34.54 | $30.22 |
| Region III | $42.40 | $33.93 | $29.68 |
(c) Fee schedules effective October 1, 2010. The hourly AHRH fees shall incorporate health care adjustment (HCA) VI funding equivalent to a 1.0 percent increase in the applicable standard regional fee that was in effect on April 1, 2010.
(1) AHRH Direct Support—Individual—Fee is hourly.
| Standard Regional Fee | Level 1 Transitional Fee | ||
| Region I | $39.56 | $44.86 | |
| Region II | $40.65 | $61.53 | |
| Region III | $39.56 | $51.79 |
(2) AHRH Direct Support—Group Services—Fee is hourly per person.
(i) Group Standard Regional Fees
| Serving 2 Individuals | Serving 3 Individuals | Serving 4 or more Individuals | |
| Region I | $24.73 | $19.78 | $17.31 |
| Region II | $25.40 | $20.32 | $17.78 |
| Region III | $24.73 | $19.78 | $17.31 |
(ii) Group Level I Transitional Fees
| Serving 2 Individuals | Serving 3 Individuals | Serving 4 or more Individuals | |
| Region I | $28.03 | $22.43 | $19.62 |
| Region II | $38.45 | $30.76 | $26.92 |
| Region III | $32.37 | $25.89 | $22.66 |
(3) In addition to the prospective add-on for HCA VI, providers shall receive HCA VI funds in an amount that they would have received if the health care adjustment VI had been in effect for the period from April 1, 2010 through September 30, 2010.
(c) Day habilitation services.
(2) Day habilitation services shall be reimbursed as either individual day habilitation, supplemental individual day habilitation, group day habilitation or supplemental group day habilitation. Effective October 1, 2015, individual day habilitation services and supplemental individual day habilitation services are no longer available. Subparagraphs (i) and (ii) of this paragraph are retained for such services that were delivered prior to October 1, 2015.
(3) An annual price period is a 12-month period as follows:
(4) Day habilitation service costs are those costs related to the aggregate of all services selected and identified in the individualized service plan (ISP) and day habilitation plan for each person participating in the program.
(vi) Allowable capital costs for group day habilitation services shall be reimbursed. Effective January 1, 2009, the capital cost portion for group day habilitation shall be included in the group day habilitation price as follows:
(b) Effective January 1, 2011, capital moveable equipment and property insurance shall become fixed values contained in the cost category other than personal services.
(5) The unit of service for individual day habilitation and supplemental individual day habilitation services provided prior to October 1, 2015, shall be one hour equaling 60 minutes and is reimbursed in 15-minute increments. When there is a break in the service delivery during a single day, for billing purposes, the provider may combine the duration of each non-continuous period of service provision (or "session") that is provided during the day, when at least one service/staff action delivered in accordance with the individual's day habilitation plan is documented for each session.
(iii) Billable service time is time when staff are providing face-to-face individual day habilitation or supplemental individual day habilitation services to an individual in accordance with the individual's day habilitation plan. The following cannot be counted toward the individual day habilitation or supplemental individual day habilitation billable service time:
(iv) When individual day habilitation or supplemental individual day habilitation staff provide time-limited travel training services to a individual who is traveling to the first individual day habilitation or supplemental individual day habilitation activity of the day and traveling home or to another service at the conclusion of the individual day habilitation or supplemental individual day habilitation service, the time spent receiving travel training services may be counted as billable service time as long as:
(6) Unit of service for reimbursement of group day habilitation and supplemental group day habilitation.
(i) Group day habilitation and supplemental group day habilitation services are reimbursed in full or half units of service:
(ii) The program day duration for both group day habilitation and supplemental group day habilitation is the length of time that the person is participating in the group day habilitation or supplemental group day habilitation services. The following cannot be counted as part of the program day duration:
(iii) Supplemental group day habilitation services may not be billed to Medicaid for:
(7) Billing limits for group day habilitation, supplemental group day habilitation, and prevocational services (see subdivision [e] of this section) delivered before July 1, 2015. (See paragraph [17] of this subdivision for billing limits for group day habilitation and supplemental day habilitation delivered on and after July 1, 2015).
(i) Limit of one full unit or two half units.
(a) This limit applies to an individual who, on a given day:
(b) On a given day, a maximum of the following may be reimbursed:
(ii) Limit of one and a half units or three half units.
(b) On a given day, a maximum of the following may be reimbursed:
(v) Exceptions. The following applies only to requests made prior to October 1, 2014.
(b) The billing limits established in subparagraph (ii) of this paragraph may be waived on an individual basis by the commissioner if the commissioner finds, based on the request submitted by the agency:
(9) Effective July 1, 1996, costs associated with the provision of transportation shall be allowable costs. These costs shall be determined for each day habilitation program using the following methodology.
(i) Using a payment/rate data sample from calendar years 1995 and 1996, the weighted transportation average shall be calculated by dividing the aggregate transportation payments by the aggregate transportation units of service. One round trip shall equal one unit of service.
(a) The weighted transportation average for each day habilitation program shall be ranked among all day habilitation programs statewide.
(b) After deducting the 40 percent to be held harmless, the net weighted transportation average for each day habilitation program (i.e., the remaining 60 percent of the weighted transportation average) shall be re-ranked. Based on the new percentile rankings, a percentage offset shall be deducted from the net weighted transportation average. A program's percentage offset shall be determined by locating its net weighted transportation average (i.e., the remaining 60 percent of the weighted transportation average) in the following table:
| Percentile Rank | Net Weighted Transportation Average | Percentage Offset |
|---|---|---|
| 5 or < | $0 - $4.59 | 5 |
| 6 to 9 | $4.60 - $6.69 | 7.5 |
| 10 to 29 | $6.70 - $9.59 | 10 |
| 30 to 49 | $9.60 - $12.18 | 12.5 |
| 50 to 59 | $12.19 - $13.76 | 15 |
| 60 to 69 | $13.77 - $13.79 | 16.5 |
| 70 to 79 | $13.80 - $14.44 | 20 |
| 80 to 84 | $14.45 - $15.71 | 22.5 |
| 85 or > | Over $15.71 | 25 |
(c) The amount remaining after the application of the percentage offset (the 60 percent of the weighted transportation average reduced by the offset percentage in the table above) shall be added to the hold harmless amount to determine a program's modified weighted transportation average.
(iv) If the agency does not currently operate a day habilitation program or day treatment facility, the modified weighted transportation average shall be equal to the lesser of the new day habilitation program's budgeted amount for transportation based on the transportation requirements of the persons to be transported to and from the new day habilitation program or 75 percent of the regional modified weighted transportation average associated with transporting individuals to and from day habilitation programs. The table below shows the regional modified weighted transportation averages:
| Region | Average | 75 Percent of Average |
| 1 | $20.85 | $15.64 |
| 2 | $18.22 | $13.67 |
| 3 | $17.32 | $12.99 |
(v) Agencies that operated only day treatment facilities prior to July 1, 1996, and opened a day habilitation program for the first time between July 1, 1996 and September 3, 1996 shall receive a one time fee adjustment if the agency received 75 percent of the regional modified weighted transportation average for day habilitation transportation and is now receiving either the new day habilitation program's budgeted transportation amount or the average of the agency's day treatment modified weighted transportation averages. The one time fee adjustment shall be either:
(14) Effective January 1, 2006, for all regions there shall be an efficiency adjustment to day habilitation programs as described herein applied as a reduction to reimbursable operating costs.
(i) A determination shall be made as to whether each provider has a surplus or loss for all its day habilitation programs.
(a) Surplus/loss shall equal the difference between costs and the greater of:
(b) For purposes of this efficiency adjustment:
(ii) Regional ranking of the surplus/loss.
(b) Within each region, the ranking is dividend into five groups:
| Region I | Surplus/loss range |
| Efficiency Group 5 | $622,373 or more |
| Efficiency Group 4 | $158,879 to $622,372 |
| Efficiency Group 3 | $ 73,343 to $158,878 |
| Efficiency Group 2 | $ 2,353 to $ 73,342 |
| Efficiency Group 1 | $ 2,352 or less |
| Region II | Surplus/loss range |
| Efficiency Group 5 | $229,056 or more |
| Efficiency Group 4 | $ 75,604 to $229,055 |
| Efficiency Group 3 | $ 70,116 to $ 75,603 |
| Efficiency Group 2 | $ 2,575 to $ 70,115 |
| Efficiency Group 1 | $ 2,574 or less |
| Region III | Surplus/loss range |
| Efficiency Group 5 | $206,347 or more |
| Efficiency Group 4 | $ 69,121 to $206,346 |
| Efficiency Group 3 | $ 21,400 to $ 69,120 |
| Efficiency Group 2 | $(8,598) to $ 29,399 |
| Efficiency Group 1 | $ (8,599) or more |
(iii) Determination of total adjustment per fee.
(iv) Exceptions to assignment of efficiency group.
(v) Recalculation of surplus/loss.
(15) Effective May 1, 2010, for all regions there shall be an efficiency adjustment to group day habilitation and supplemental group day habilitation prices. The efficiency adjustment shall take the form of a two-tiered reduction in reimbursable operating costs as follows:
(ii) The second tier adjustment shall be applied to all non-personal services (NPS) reimbursable operating costs reflected in the reimbursement prices for providers at or above the benchmark described in clause (b) of this subparagraph.
(16) Effective July 1, 2011, group day habilitation and supplemental group day habilitation prices shall be reduced according to the measures outlined in this paragraph. There are two distinct actions to the price reductions. The personal services action addresses provider surpluses in funding for direct care, clinical and support staff and the associated fringe benefits. The administrative action addresses reimbursable administrative costs and holds reimbursement to a level of efficiency. Providers may be subject to only one action or to both actions or they may be exempt from both.
(ii) Personal services surpluses action.
(a) Exemptions.
(1) Providers with FTE personal services losses and actual personal services fringe benefit percentages greater than the reimbursable percentages are exempt. To qualify for this exemption, a provider must meet each of the two criteria which follow.
(iii) Administrative action.
(a) Exemptions.
(c) Tentative aggregate gross reduction. For providers subject to the administrative action, OPWDD used the compensation data also used in subclause (a)(2) of this subparagraph and the reported number of FTEs corresponding to those administrative titles as reported in providers' 2008/2008-2009 cost reports. OPWDD computed a provider-specific average compensation per FTE for the administrative titles. Similarly, OPWDD computed a provider-specific average compensation per FTE for direct care, clinical and support staff using data from providers' 2008/2008-2009 cost reports. (Direct care, clinical and support staff collectively are referred to as direct support staff.) The compensation data for both administrative titles and direct support titles included fringe benefits. A ratio of average administrative compensation to average direct support compensation was determined for each provider. Providers' ratios were then ranked and separated into five graduated levels. A reduction percentage was established to correspond to each level of compensation ratios. The reduction percentage for a provider is dependent on a provider's positioning in the five levels. The following chart gives the explicit ranges for the compensation ratios and the applicable reduction percentages. The tentative aggregate gross reduction equals the reduction percentage determined by a provider's ranking in the compensation ratio comparisons applied to that provider's aggregate reimbursable administrative costs as reflected in the corresponding price(s) at June 30, 2011.
| Compensation Ratios | Reimbursable Administrative Costs |
| Administration to Direct Support | Reduction Percentage |
| Equal to or greater than 10.0:1 | 9.0% |
| Equal to or greater than 6.0:1 but less than 10.0:1 | 7.5% |
| Equal to or greater than 4.0:1 but less than 6.0:1 | 6.0% |
| Equal to or greater than 3.0:1 but less than 4.0:1 | 4.0% |
| Less than 3.0:1 | 2.0% |
(17) Limits on billable service time.
(i) On a given weekday, a maximum of the following may be reimbursed for group day habilitation services:
(b) the combination of:
(c) additional combinations:
(1) for individuals residing in individualized residential alternatives (IRAs), community residences (CRs) and Family Care Homes:
(2) for individuals who receive one half unit of supplemental group day habilitation:
(iii) On a given weekend day a maximum of the following may be reimbursed for supplemental group day habilitation:
(b) the combination of:
(18) During the period beginning on July 22, 2020 and ending on October 14, 2020, due to the COVID-19 Public Health Emergency, providers billing for services rendered using the flexible definitions of the program day duration for day habilitation authorized by paragraph (6)(i)(c) of this subdivision are subject to all the following conditions:
(19) Beginning on October 15, 2020 and ending upon revocation by OPWDD, due to the COVID-19 Public Health Emergency, providers will be authorized to bill for services rendered using the flexible definitions of the program day duration for day habilitation authorized by clause (6)(i)(d) of this subdivision if either subparagraph (i) or (ii) and subparagraph (iii) of this paragraph are met:
(iii) providers will continue to work in partnership with OPWDD to make more available non-center-based and telehealth modalities in an effort to increase community involvement of waiver enrollees and to protect the delivery of services during future emergencies.
(d) Supported employment (SEMP) services prior to July 1, 2015.
(For SEMP provided on and after July 1, 2015, see subdivision [af] of this section.)
(1) Reimbursement for HCBS waiver supported employment services provided in accordance with the provisions of section 635-10.4(d) of this Subpart, shall be a monthly supported employment services fee which incorporates a level of support and varies by region, unless the provisions of subparagraph (iii) of this paragraph apply.
(ii) The level of support will be established based on information obtained in accordance with the Developmental Disabilities Profile (DDP-2) (1/87), which is a developmental/demographic inventory of each person's personal characteristics.
(a) Support points are generated as follows for each data element that is answered in the affirmative on the DDP-2:
(b) The DDP-2 (1/87) is contained in "Scoring the DDP," an OPWDD publication. This document is available from:
(2) It may also be reviewed in person during regular business hours at the:
(c) Total support points for a person are calculated by adding the support points for each element in the affirmative. Monthly supported employment service fees are payable based upon documented service delivery and will vary by level of support and by region as follows:
(1) For those providers of the service that instituted the salary enhancement for direct care and support workers, pursuant to chapter 54 of the Laws of 2000, page 389, line 36 - page 390, line 9, the monthly supported employment service fee will be as follows:
| Level of support | Total support points | NYC fees | Rest of the State fees |
|---|---|---|---|
| 1 | less than .7534 | $359 | $257 |
| 2 | greater than or equal to .7534 and less than 2.9505 | $480 | $343 |
| 3 | greater than or equal to 2.9505 | $540 | $387 |
(2) For all other providers of the service the fee is as follows:
| Level of support | Total support points | NYC fees | Rest of the State fees |
|---|---|---|---|
| 1 | less than .7534 | $349 | $250 |
| 2 | greater than or equal to .7534 and less than 2.9505 | $470 | $336 |
| 3 | greater than or equal to 2.9505 | $530 | $380 |
(3) Fees effective January 1, 2010. Effective January 1, 2010, there shall be one schedule of fees for all providers of supported employment services. The monthly fees shall incorporate health care adjustments (HCE I through III and HCA IV and V) equivalent to a 1.0 percent funding increase per adjustment applied to the fees sequentially to effect compounding of the adjustments.
| Level of support | Total support points | NYC fees | Rest of the State fees |
|---|---|---|---|
| 1 | less than .7534 | 517 | 371 |
| 2 | equal to or greater than .7534 and less than 2.9505 | 691 | 494 |
| 3 | equal to or greater than 2.9505 | 779 | 558 |
(4) Effective October 1, 2010, the monthly fees shall incorporate health care adjustment (HCA) VI funding equivalent to a 1.0 percent increase applied to the fees in effect on April 1, 2010.
| Level of support | Total support points | NYC fees | Rest of the State fees |
|---|---|---|---|
| 1 | less than .7534 | $549 | $394 |
| 2 | equal to or greater than .7534 and less than 2.9505 | $734 | $525 |
| 3 | equal to or greater than 2.9505 | $828 | $593 |
(6) Effective July 1, 2011, the fees are as follows:
| Level of support | Total support points | NYC fees | Rest of the State fees |
|---|---|---|---|
| 1 | less than .7534 | $538 | $386 |
| 2 | greater than or equal to .7534 and less than 2.9505 | $720 | $515 |
| 3 | greater than or equal to 2.9505 | $812 | $581 |
(7) Reimbursement for HCBS waiver supported employment services shall be claimed on a person-specific basis. The unit of service for supported employment services shall be a calendar month.
(10) The fees determined in accordance with this subdivision shall not be considered final unless approved by the Director of the State Division of the Budget.
(e) Prevocational services delivered before July 1, 2015.
(2) An annual price period is a 12-month period as follows:
(5) Reimbursement for prevocational services shall be determined through a budget review process.
(iv) Effective January 1, 2009, the capital cost portion for prevocational services shall be reimbursed as follows:
(6) Effective July 1, 2011, prevocational services prices shall be reduced according to the measures outlined in this paragraph. This personal services action addresses provider surpluses in funding for direct care, clinical and support staff and the associated fringe benefits.
(ii) Exemptions.
(8) Unit of service for reimbursement for prevocational services.
(i) Reimbursement for prevocational services shall be claimed on an individual basis. Prevocational services shall be billed on a full and half unit basis.
(ii) The program day duration for prevocational services is the length of time that the person is present at the provider's "vocational/work program" where prevocational services are provided. The following cannot be counted as part of the program day duration:
(9) Billing limits for prevocational services, group day habilitation, and supplemental group day habilitation (see subdivision [c] of this section).
(i) Limit of one full unit or two half units.
(a) This limit applies to an individual who, on a given day:
(b) On a given day, a maximum of the following may be reimbursed:
(ii) Limit of one and a half units or three half units.
(b) On a given day, a maximum of the following may be reimbursed:
(vi) Exceptions. The following applies only to requests made prior to October 1, 2014.
(b) The billing limits established in subparagraph (ii) of this paragraph may be waived on an individual basis by the commissioner if the commissioner finds, based on the request submitted by the agency:
(10) Reimbursement of prevocational services delivered in sheltered workshops.
(i) Effective July 1, 2013, reimbursement of prevocational services delivered in a sheltered workshop is limited to those individuals who:
(iii) Reimbursement of prevocational services delivered in a sheltered workshop is limited to services provided to the individuals specified in subparagraphs (i) and (ii) of this paragraph by either:
(14) The price determined in accordance with this subdivision shall not be considered final unless approved by the Director of the State Division of the Budget.
(f) Environmental modifications.
(1) Reimbursement for environmental modifications shall be made pursuant to a contract between OPWDD and a contractor (see paragraph [4] of this subdivision) and subject to Subpart 635-6 of this Part. Notwithstanding the application of Subpart 635-6 of this Part to environmental modifications, OPWDD shall not be required to pay a contractor over the useful life of the environmental modification, but rather shall pay the contractor at the times set forth in the contract. The contract shall be approved by the DDSO director, based on the availability of funds and in compliance with the following requirements:
(4) For the purposes of reimbursement of environmental modifications services and adaptive technologies services of the home and community-based services waiver only, the term contractor may include a person enrolled in the HCBS waiver, an advocate (as defined in section 635-99.1 of this Part), a not-for-profit agency, or a family care provider who enters into an agreement with a DDSO for the reimbursement of costs incurred in obtaining environmental modification or adaptive technology services.
(g) Adaptive technologies.
(1) Reimbursement for adaptive technologies shall be made pursuant to a contract between OPWDD and a contractor (see paragraph [5] of this subdivision) and subject to Subpart 635-6 of this Part. The contract shall be approved by the DDSO director, based on the availability of funds and in compliance with the following requirements:
(5) For the purposes of reimbursement of environmental modifications and adaptive technology services of the home and community-based services waiver only, the term contractor may include a person enrolled in the HCBS waiver, an advocate (as defined in section 635-99.1 of this Part), a not-for-profit agency, or a family care provider who enters into an agreement with a DDSO for the reimbursement of costs incurred in obtaining environmental modifications or adaptive technology services.
(h) Respite services.
(4) Effective July 1, 2017, respite services must be authorized and delivered as one of the following types of service categories:
(iii) Site-based respite services. Services are provided on a property that the provider owns, leases, or for which the provider pays property costs or usage fees. The property may be:
(v) Intensive respite services. Services provided based on an individual’s level of need rather than the location. Individuals must be authorized to receive these services by OPWDD regional offices.
(a) High behavioral needs. Services provided to individuals with high behavioral needs that meet the qualifications for additional staffing supports and are overseen by:
(3) a START clinical team leader;
(b) High medical needs. Services provided to individuals with high medical needs that meet the qualifications for additional staffing supports and are overseen by licensed clinical professionals including, but not limited to: a physician; physician assistant (PA); special assistant; registered professional nurse (RN); nurse practitioner; clinical nurse specialist; and/or a licensed practical nurse (LPN).
(5) Billing limits.
(ii) Overnight respite is defined as respite services provided to a person on two consecutive days when respite staff are providing oversight to a person during nighttime hours. Overnight respite services may be delivered for in-home, site based, camp, and intensive respite service categories.
(7) Authorization processes.
(i) In-home, camp, site-based and recreational respite services:
(ii) Intensive respite services:
(9) Service documentation. Service documentation must be contemporaneous with respite service provision. Service documentation must include the following elements:
(10) Individualized service plan (ISP)/life plan (LP). The ISP/LP must include the following elements related to the respite service:
(i) Trend factors applicable to reimbursement fees for HCBS waiver services as specified herein, determined in accordance with this section or section 686.13(i) of this Title.
(1) Except for at home residential habilitation as of February 1, 2009, plan of care support services and family education and training, the following applies to HCBS waiver providers in Region I, including those providers in Region II or III designated or elected to a Region I reporting year-end and fiscal cycle and excluding those HCBS waiver providers in Region I designated or elected to a Region II or III reporting year- end and fiscal cycle. For providers in operation on June 30th, the appropriate trend factor shall be applied to the operating portion, exclusive of property, of the price or fee in effect on June 30th:
(xxvii) 0.00 percent to trend 2008-2009 costs to 2009-2010.
(xxviii) Effective February 1, 2010, facilities shall receive an amount that they would have received if the trend factor in subparagraph (xxvii) of this paragraph for the price or fee period of July 1, 2009 through June 30, 2010 had been 3.06 percent. The trend factor in effect for the price or fee 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. In addition, for agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.
(2) Except for at home residential habilitation as of February 1, 2009, plan of care support services and family education and training, the following applies to HCBS waiver providers in Regions II and III, including those providers in Region I designated or elected to a Region II or III reporting year-end and fiscal cycle and excluding those HCBS waiver services providers in Regions II and III designated or elected to a Region I reporting year-end and fiscal cycle. For providers in operation on December 31st, the appropriate trend factor shall be applied to operating portion, exclusive of property, of the price or fee in effect on December 31st:
(ix) To trend calendar 1995 costs to calendar year 1996:
(xxvii) 0.00 percent to trend calendar 2008 costs to calendar year 2009.
(xxviii) Effective February 1, 2010, facilities shall receive an amount that they would have received if the trend factor in subparagraph (xxvii) of this paragraph for the price or fee period of January 1, 2009 through December 31, 2009 had been 3.06 percent. The trend factor in effect for the calendar year price or fee 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. In addition, for agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.
(3) Effective February 1, 2010, for at home residential habilitation (AHRH) programs operating after January 31, 2009, only the standard regional fees shall be trended.
(4) Effective February 1, 2010, reimbursement for plan of care support services (PCSS) and family education and training (FET) shall be trended for the years indicated as follows:
(ii) 2.08 percent to trend 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.
(j) Determination of the efficiency adjustment.
(1) The efficiency adjustment shall be a percentage reduction applied to the actual reimbursement for administration in the fee for residential habilitation services and day habilitation services. Except as provided for in paragraph (2) of this subdivision, all cost and revenue information used to determine the efficiency adjustment percentages, as described herein, shall be based on reported expense and revenue information for the calendar 1992 or 1992-93 cost reporting year. Each provider shall be assigned a percentage value from the table at subparagraph (iii) of this paragraph, based on a program surplus/deficit group designation and an administration percentage group designation. This percentage value shall be used to determine the amount by which existing reimbursement for administration will be reduced in the current fee.
(i) Determination of program surplus/deficit group designation. A determination shall be made as to whether each provider has a program surplus or deficit, for the combined total of all of its community residence and day treatment programs and all individualized residential alternative and at home residential habilitation and day habilitation services. Surplus/deficit shall equal gross revenue (less any prior period adjustments) minus allowable costs.
(b) For those providers with a reported program surplus, a certain portion of that surplus shall be exempted to establish an adjusted surplus. The adjusted surplus shall be the reported surplus minus the exempt amount. Exempt amounts shall be determined as follows. For providers whose total program costs are:
(c) The reported deficit or the adjusted surplus shall be given one of the following group designations used to determine the efficiency adjustment percentage in the table at subparagraph (iii) of this paragraph.
(ii) Determination of a calculated administration percentage group. A determination shall be made of a provider’s calculated administration percentage, where administration percentage shall equal the sum of agency administration plus the program administration divided by the result of total program cost minus the sum of capital costs, agency administration and program administration. There shall be five group designations that express the calculated administration percentage as a departure from the regional average percentage for all provider agencies within a total program cost size designation. Those percentages centered around the average are designated with the abbreviation AVG. There are also two group designations for percentages over the average, abbreviated OA2 and OA1 and two group designations for under the average, abbreviated UA2 and UA1. These abbreviations appear in subparagraph (iii) of this paragraph as well as in the following regional tables. Each provider's assignment to one of the five group designations shall be based on the provider's calculated administration percentage, total program cost and elected or assigned region (refer to section 686.13[c][1][vii] of this Title). Each provider's administration percentage group designation shall be determined using the following tables. REGION ONE Program Cost in Millions of Dollars (< less than; > greater than) REGION TWO Program Cost in Millions of Dollars (< less than; > greater than) REGION THREE Program Cost in Millions of Dollars (< less than; > greater than)
REGION ONE
Program Cost in Millions of Dollars (< less than; > greater than)
| < $1 | $1 to < $3 | $3 to $7 | > $7 | |
| Administration Percentage | Group | |||
| .3100 PLUS | .4500 PLUS | .4500 PLUS | .4500 PLUS | OA2 |
| .2600.3099 | .3500.4499 | .3500.4499 | .3500.4499 | OA1 |
| .2300.2599 | .3200.3499 | .3200.3499 | .2800.3499 | AVG |
| .1900.2299 | .2500.3199 | .2400.3199 | .2400.2799 | UA1 |
| .0000.1899 | .0000.2499 | .0000.2399 | .0000.2399 | UA2 |
REGION TWO
Program Cost in Millions of Dollars (< less than; > greater than)
| < $1 | $1 to < $3 | $3 to $7 | > $7 | |
| Administration Percentage | Group | |||
| .3100 PLUS | .4500 PLUS | .3500 PLUS | .3500 PLUS | OA2 |
| .2900.3099 | .3500.4499 | .2800.3499 | .2500.3499 | OA1 |
| .2150.2899 | .3200.3499 | .2500.2799 | .1900.2499 | AVG |
| .1900.2149 | .2500.3199 | .2000.2499 | .1700.1899 | UA1 |
| .0000.1899 | .0000.2499 | .0000.1999 | .0000.1699 | UA2 |
REGION THREE
Program Cost in Millions of Dollars (< less than; > greater than)
| < $1 | $1 to < $3 | $3 to $7 | > $7 | |
| Administration Percentage | Group | |||
| .4200 PLUS | .3500 PLUS | .2800 PLUS | .4200 PLUS | OA2 |
| .3300.4199 | .2700.3499 | .2550.2799 | .3300.4199 | OA1 |
| .2400.3299 | .2250.2699 | .2300.2549 | .2400.3299 | AVG |
| .1851.2399 | .1900.2249 | .2100.2299 | .1851.2399 | UA1 |
| .0000.1850 | .0000.1899 | .0000.2099 | .0000.1850 | UA2 |
(iii) Determination of the efficiency adjustment percentage. Each provider shall be assigned an efficiency adjustment percentage value from the following table, based on the surplus/deficit group designation and the administration percentage group designation. This efficiency adjustment percentage shall be applied to costs reimbursed for administration in the fees for residential habilitation and day habilitation services.
| S2 | S1 | BE | D1 | D2 | |
| OA2 | 10.00% | 8.50% | 7.00% | 5.50% | 4.00% |
| OA1 | 9.00% | 7.50% | 6.00% | 4.50% | 3.00% |
| AVG | 8.00% | 6.50% | 5.00% | 3.50% | 2.00% |
| UA1 | 7.00% | 5.50% | 4.00% | 2.50% | 1.00% |
| UA2 | 6.00% | 4.50% | 3.00% | 1.50% | 0.00% |
(2) Providers may request that OPWDD use a more recent cost reporting period, as an alternative to their 1992 or 1992-93 reporting period, to determine the efficiency adjustment percentage as described herein. Approval to use an alternative reporting period shall be granted if, upon a fiscal review by the commissioner, it is determined that the cost report for the alternative reporting period more accurately reflects the provider's current financial status. For the purposes of determining the efficiency adjustment percentage only, providers may submit corrections to their 1992 or 1992-93 cost report. Such corrections shall be certified by a certified public accountant. Providers may request the use of an alternative reporting period or may submit corrections to their 1992 or 1992-93 cost report only once. Such requests or corrections shall be made in writing and received by OPWDD by December 31, 1996. Providers shall also have until December 31, 1996 to notify OPWDD of errors made in calculating the efficiency adjustment.
(k) Employee health care enhancement (HCE).
(3) Effective January 1, 2006, providers may receive additional funding as follows:
(ii) Providers whose employee health care benefits and below the benchmark may apply to OPWDD for additional funding as follows:
(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.
(ii) Providers whose employee health care benefits are below the benchmark may apply to OPWDD for additional funding as follows:
(8) 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 II.
(5) 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 employee included in the provider's approved HCE II application multiplied by $2,500. Funding at the $2,500 level is available to providers which:
(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:
(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.
(m) Employee health care enhancement III.
(3) 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.
(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 fee or price in effect on January 1, 2008 net of any funding provided pursuant to subparagraph (iii) of this paragraph.
(4) A fee or price 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 adjustments (HCA) IV and V.
(3) HCA IV and HCA V funding effective November 1, 2009 for services and programs described in paragraphs (b)(1)-(18) and subdivisions (c), (e) and (h) of this section.
(i) Providers eligible for HCA IV and HCA V funding at the benchmark level.
(ii) Providers eligible for HCA IV and HCA V funding below the benchmark level may apply to OPWDD to receive this funding.
(4) Catch-up provisions.
(5) Consolidation of HCE and HCA funds effective January 1, 2010.
(6) Provider's 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.
(o) Health care adjustment (HCA) VI.
(3) HCA VI funding effective October 1, 2010 for services and programs described in paragraphs (b)(1)-(18) and subdivisions (c), (e), and (h) of this section.
(i) Providers eligible for HCA VI funding at the benchmark level.
(ii) Providers eligible for HCA VI funding below the benchmark level may apply to OPWDD to receive this funding.
(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.
(p)-(z) [Reserved]
(aa) Family education and training.
(1) Definitions applicable to this subdivision:
(2) Reimbursement eligibility.
(3) Method of reimbursement and payment.
(x) Reimbursement for family education and training shall be contingent upon the services being delivered as specified in the person's individualized service plan.
(ab) Hourly community habilitation (CH) services.
The following shall apply to CH services (see section 635-10.4[b][3] of this Subpart).
(1) Eligibility for CH services.
(i) The following individuals are eligible to receive CH services:
(2) Reimbursement shall be contingent upon prior OPWDD approval of the person's need for CH services.
(3) Reimbursement shall be contingent on documentation that those receiving CH services have received the services in accordance with the person's individualized service plan (ISP) and hourly community habilitation plan (CH plan).
(7) Time spent receiving another Medicaid service cannot be counted toward the CH billable service time, except as follows:
(i) If the individual lives in a setting which is not certified or operated by OPWDD (e.g., a private home) or a FCH:
(e) CH may be billed when the CH staff is with the individual at an appointment for a clinical service of the type specified in this subparagraph in order to facilitate the implementation of therapeutic methods and treatments. The time when an individual is being transported to and from the appointment may also be counted as long as the staff accompanies the individual and Medicaid is not being charged for a transportation attendant for the trip.
(ii) For individuals who live in an IRA or CR:
(9) For each continuous service delivery period or session, the CH provider must document:
(11) Billing limits for individuals who live in an IRA, CR, or FCH.
(ii) On a given weekday, a maximum of the following may be reimbursed:
(b) the combination of:
(13) CH which is self-directed or family-directed. The following requirements apply to CH services which are self-directed or family-directed, and are in addition to all other provisions of this subdivision.
(iii) CH services which are self-directed are available when all parties to the co-management agreement concur that the individual receiving the CH services:
(b) is an adult who:
(c) is a minor and there is an identified adult who is either:
(vi) The following responsibilities (except as noted in subparagraph [vii] of this paragraph) shall be the individual's and/or the identified adult's:
(viii) The provider's responsibilities shall include:
(14) Community habilitation fee setting.
(i) Hourly fee schedule structure. Hourly fees are based on the following:
(a) The Region in which the individual lives - Region I, Region II or Region III.
(ii) Transitional hourly fees.
(iii) Fee schedules.
(b) Effective July 1, 2011, the fees are as follows:
| CH Direct Support—Fee is hourly per person | ||||
| Individual | Group | Group | Group | |
| Serving 1 | Serving 2 | Serving 3 | Serving 4 | |
| Region I | $38.78 | $24.24 | $19.39 | $16.97 |
| Region II | $39.85 | $24.91 | $19.93 | $17.44 |
| Region III | $38.78 | $24.24 | $19.39 | $16.97 |
(c) The following fees will be effective on October 1, 2012 or the date as of which necessary Federal approval is effective, whichever is later:
| CH Direct Support—Fee is hourly per person | ||||
| Individual | Group | Group | Group | |
| Serving 1 | Serving 2 | Serving 3 | Serving 4 | |
| Region I | $37.05 | $23.16 | $18.53 | $16.21 |
| Region II | $38.39 | $23.99 | $19.20 | $16.80 |
| Region III | $37.51 | $23.44 | $18.76 | $16.41 |
(d) Effective October 1, 2014, the fees for CH delivered to an individual who lives in a CR, IRA or FCH are as follows:
| Fee is hourly per person | ||
| Individual Serving 1 | Group Serving 2-4 | |
| Region I | $37.05 | $23.16 |
| Region II | $38.39 | $23.99 |
| Region III | $37.51 | $23.44 |
(17) Use of funds.
(iii) The fees contain funding for clinical oversight. Clinical oversight includes the training and mentoring of direct support staff on diagnostic issues, care plan/habilitation plan issues and behavior management issues, as well as the troubleshooting of any plan issues discovered during plan reviews. Effective October 1, 2012, clinicians must document discussions with direct support staff and include that documentation as supplemental clinical notes in individuals' files at least annually. The documentation requirement will be applicable for any 12 month period in which an individual is enrolled in CH for the entire 12 month period and has received any CH service during that period.
(ac) Community habilitation phase II (CH II) services.
The following applied to CH II services (see section 635-10.4[b][4] of this Subpart), which were delivered between October 1, 2012 and September 30, 2013 and are no longer available.
(1) Standards for the reimbursement of CH II. In order for the provider to receive reimbursement for the delivery of CH II the following standards must be met:
(2) Payment standards.
(ii) For a full month, the provider must document the delivery of:
(iii) For a half month, the provider must document the delivery of:
(3) A provider is authorized to provide CH II if it:
(4) CH II which is self-directed or family-directed. The following requirements apply to CH II services which are self-directed or family-directed.
(ii) CH II services which are self-directed are available when all parties to the co-management agreement concur that the individual receiving the CH II services:
(b) is an adult who:
(c) is a minor and there is an identified adult who is either:
(v) The following responsibilities (except as noted in subparagraph [vi] of this paragraph) shall be the individual's and/or the identified adult's:
(vii) The provider's responsibilities shall include:
(5) Price setting.
(i) On October 1, 2012, for each agency which is authorized to provide CH II (see paragraph [3] of this subdivision), OPWDD shall establish an individual CH II price that represents an amalgamation of the provider's IRA price and its group day habilitation price. It shall be calculated as follows:
(c) The non-room and board component of the individual CH II price shall be the sum of:
(iv) The individual CH II price determined through the application of this paragraph may be corrected or appealed pursuant to either section 686.13(h) or (i) of this Title, except that the determination following a first level appeal process shall be the commissioner's final decision.
(ad) Pathway to employment.
The following shall apply to the pathway to employment service.
(1) Reimbursement shall be contingent on prior OPWDD approval. OPWDD approval will be based on the following criteria:
(3) Fee setting. Hourly fees are based on the following:
(i) The region in which the individual lives - Region 1, Region 2 or Region 3.
(4) Timeframe for completion of service. The pathway to employment service is time limited to a maximum of 12 months and 278 hours of service for each individual, unless OPWDD authorizes an extension.
(ii) OPWDD’s decision on the extension request will be based on the following:
(6) Billable service time. Billable service time is:
(7) Restrictions on billable service time.
(8) Documentation. Reimbursement is contingent on compliance with the documentation requirements as follows:
(9) Use of funds. The pathway to employment service provider must ensure that Medicaid revenue billed and received for the provision of the pathway to employment service is not used to pay salaries or stipends to individuals receiving the service. Note:
Note:
See section 635-10.4(h) of this Subpart for pathway to employment allowable activities and other requirements not related to reimbursement.
(ae) Community transition services.
(2) CTS is administered by the FI services provider. The FI services provider must:
(3) Payment to the FI for CTS requires authorization from OPWDD. The authorization will be based on the following criteria:
(6) Effective November 1, 2014, the CTS payment for each individual will be the lesser of:
(ii) $3,000.
(af) Reimbursement for supported employment services provided on and after July 1, 2015.
(1) General provisions.
(i) SEMP may be delivered in two phases and provided to a single individual or small group of individuals as follows:
(a) Intensive SEMP.
(b) Extended SEMP.
(2) Intensive SEMP.
(i) Reimbursement for Intensive SEMP is contingent on an individual's eligibility for services based on the following eligibility criteria:
(3) Extended SEMP.
(i) Reimbursement for Extended SEMP is contingent on an individual's eligibility for services based on the following criteria:
(4) Extension of SEMP. Intensive or Extended SEMP services may be extended with prior authorization from OPWDD.
(ii) OPWDD’s decision on the extension request will be based on the following:
(a) For Intensive SEMP:
(b) For Extended SEMP:
(6) Billable service time. Billable service time for Intensive and Extended SEMP is:
(7) Restrictions on billable service time.
(8) Documentation.
(9) Fee setting. The fees for SEMP services are in 10 NYCRR Subpart 86-13.
(ag) Site based prevocational services.
(2) Reimbursement of site based prevocational services is contingent on prior OPWDD approval for individuals who enroll in such services. OPWDD approval will be based on the following criteria:
(4) Unit of service. Site based prevocational services shall be billed on a full and half unit basis.
(i) The agency can bill a full unit of service when the agency delivers and documents:
(ii) The agency can bill a half unit when the agency delivers and documents at least:
(iii) The following cannot be counted as part of the program day duration:
(5) Limits on billable service time.
(i) On a given weekday, a maximum of the following may be reimbursed for site based prevocational services:
(b) the combination of:
(c) additional combinations:
(1) for individuals residing in individualized residential alternatives (IRAs), community residences (CRs) and family care homes:
(2) for individuals who receive one half unit of supplemental group day habilitation:
(iii) On a given weekend day, a maximum of the following may be reimbursed for site based prevocational services for individuals not residing in IRAs, CRs, and Family Care Homes:
(b) the combination of:
(c) additional combinations:
(6) Documentation. Reimbursement is contingent on compliance with the documentation requirements as follows:
(7) During the period beginning on July 22, 2020 and ending on October 14, 2020, due to the COVID-19 Public Health Emergency, providers billing for services rendered using the flexible definitions of the program day duration for site-based prevocational services authorized by paragraph (4)(iv) of this subdivision are subject to all the following conditions:
(8) Beginning on October 15, 2020 and ending upon revocation by OPWDD, due to the COVID-19 Public Health Emergency, providers will be authorized to bill for services rendered using the flexible definitions of the program day duration for site-based prevocational services authorized by subparagraph (4)(v) of this subdivision if either subparagraph (i) or (ii) and subparagraph (iii) of this paragraph are met:
(iii) providers will continue to work in partnership with OPWDD to make more available non-center-based and telehealth modalities in an effort to increase community involvement of waiver enrollees and to protect the delivery of services during future emergencies.
(ah) Community based prevocational services.
(2) Reimbursement of community prevocational services is contingent on prior OPWDD approval for individuals who enroll in such services. OPWDD approval will be based on the following criteria:
(6) Limits on billable service time.
(i) On a given weekday, a maximum of the following may be reimbursed for community prevocational services:
(b) the combination of:
(c) additional combinations:
(1) for individuals residing in individualized residential alternatives (IRAs), community residences (CRs) and family care homes:
(2) for individuals who receive one half unit of supplemental group day habilitation:
(ii) on a given weekend day, a maximum of the following may be reimbursed for community prevocational services:
(b) the combination of:
(c) additional combinations:
(7) Documentation. Reimbursement is contingent on compliance with the documentation requirements as follows:
(a) Plan of care support services.