Part 86 Reporting and Rate Certifications for Facilities

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.

(a) Effective January 1, 1988, reported costs and statistics for a facility's annual fiscal period ending two years prior to the rate period, trended pursuant to section 86-1.58 of this Subpart, shall be used in computing Medicaid rates for care provided by community-based home h…

(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, sh…

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 pat…

(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 ide…

(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…

(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 (DR…

(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…

(a) Each medical facility shall complete and file with the department and/or its agent annual financial and statistical report forms supplied by the department and/or its agent. Medical facilities certified for title XVIII (Medicare) shall use the same fiscal year for title XIX (…

Rates of payment computed pursuant to this Subpart shall be further adjusted in accordance with the following: (a) A direct graduate medical education (GME) payment per discharge shall be added to the case payment rates of teaching general hospitals after the application of SIW a…

(1) High cost out lierrates of payment shall be calculated by reducing total billed patient charges, as approved by IPRO, to cost, as determined based on the hospital's ratio of cost to charges. Such calculation shall use the most recent data available as subsequently updated to …

(a) Hospitals shall be reimbursed for ALC days at the appropriate 1987 group average operating cost component of rates of payment for hospital-based residential health care facilities established pursuant to Subpart 86-2 of this Part trended to the rate year. The determination of…

(a) Physical medical rehabilitation inpatient services shall qualify for reimbursement pursuant to section 2807-c(4)(e-2) of the Public Health Law for periods on and after December 1, 2009, only if such services are provided in a hospital specializing in such services or in a dis…

The commissioner shall establish trend factors for hospitals to project the effects of price movements on historical operating costs. Rates of payment excluding capital, as calculated pursuant to the provisions of this Subpart, shall be trended to the applicable rate year by the …

(a) The allowable costs of fixed capital (including but not limited to depreciation, rentals and interest on capital debt), and major movable equipment shall be reimbursed based on budgeted data and shall be reconciled to total actual expense for the rate year and shall be determ…

Each general hospital shall be assessed an annual fee calculated on the basis of the hospital's proportionate share of the sum of total costs reported by all general hospitals in the most recent calendar year for which certified data are available. Such amount shall not exceed on…

In the event the State cannot provide assurances satisfactory to the secretary of the Department of Health and Human Services related to a comparison of rates of payment for general hospital inpatient services to beneficiaries of the title XIX program determined in accordance wit…

(a) Notification of the elimination of a general hospital inpatient service or identifiable unit of such a service in instances in which the costs of such service are reflected in the rate calculated pursuant to this Subpart shall be submitted in writing by the facility to the de…

Payments to new hospitals without adequate cost experience for inpatient acute care services that are not exempt from DRG case-based rates of payment shall be computed in accordance with this Subpart except as follows: (1) Rates of payment shall be computed on the basis of 100 pe…

(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, …

(1) For purposes of this section, eligible hospitals shall mean those hospitals fined as rural hospitals and meeting the swing bed program requirements in Part 406 of this Title. (2) Rate shall mean the aggregate governmental payment made to eligible facilities per patient day as…

As used in this section, the terms merger, acquisition and consolidation shall mean the combining of two or more general hospitals licensed under article 28 of the Public Health Law, where such combination is consistent with the public need, would create a new, more economical en…

(a) Administrative rate appeals of rates of payment issued pursuant to this Subpart must be submitted to the department in writing within 120 days of the date such rates are issued by the department to the facility. Such rate appeals must set forth in detail the basis for such ap…

(a) For discharges occurring on and after December 1, 2009, rates of payment for inpatient hospital services provided by out-of-state providers in accordance with the prior approval requirements set forth in section 365-a(4)(d) of the Social Services Law shall be as follows: (1) …

(a) For the period prior to December 31, 2009: (1) $307 million shall be distributed to facilities designated by the department as teaching hospitals as of December 31, 2008, to compensate such facilities for Medicaid and self-pay losses pursuant to the following schedule of paym…

(a) Disproportionate share payment distributions made to general hospitals pursuant to article 28 of the Public Health Law shall be limited in accordance with the provisions of this section. The latest available annual cost report submitted by a hospital prior to the disproportio…

(a) With the exception of hospitals designated under the Medicare program as meeting the criteria set forth in section 1861(b)(7) of the Federal Social Security Act, for discharges occurring on and after February 1, 2010, hospitals may bill for physician services in accordance wi…

(a) For discharges occurring on and after July 1, 2010, Medicaid rates of payment to hospitals that have an excess number of readmissions as defined in accordance with the criteria set forth in subdivision (c) of this section, as determined by a risk adjusted comparison of the ac…

(a) Subject to the availability of Federal financial participation, the commissioner may, for rate periods effective on and after October 20, 2010, increase inpatient Medicaid fee-for-service rates subject to this Subpart for the following periods and in the following amounts: (1…

Inpatient psychiatric services provided in general hospitals, or distinct units of general hospitals, specializing in such inpatient psychiatric services, with regard to patients admitted on and after October 20, 2010, shall be reimbursed on a per diem basis in accordance with th…

(a) All fiscal and statistical records and reports shall be subject to audit. All underlying books, records and documentation which formed the basis for the fiscal and statistical reports, filed by the medical facility with the department, shall be kept and maintained by the faci…

(a) For the period July 1, 2011 through March 31, 2012 a quality contribution shall be imposed on the inpatient revenue of each general hospital that is received for the provision of inpatient obstetrical patient care services in an amount equal to 2.4 percent of such revenue, as…

(a) Effective for discharges occurring on or after July 1, 2011, payments pursuant to this Subpart shall be denied with regard to the following potentially preventable negative outcomes if they are acquired during a patient's inpatient stay at the hospital seeking such payments: …

(a) Effective for services provided on and after April 1, 2011 through March 31, 2012, Medicaid payments for certified home health care agencies (agencies), except for such services provided to children under 18 years of age, shall reflect ceiling limitations determined in accord…

(a) Effective for services provided on and after May 2, 2012, Medicaid payments for certified home health care agencies (CHHA), except for such services provided to children under 18 years of age and except for services provided to a special needs population of medically complex …

For hospital inpatient services, in addition to the inpatient rates of payment computed in accordance with this Subpart, a separately billable rate of payment shall be available for providing language assistance services, if applicable, in accordance with the following: (a) A dis…

For purposes of this section, the following definitions shall apply: (1) Clinical research means patient-oriented research, epidemiologic and behavioral studies, or outcomes research and health services research that are approved by an institutional review board by the time the r…

(a) Effective for periods on and after January 1, 2013, payments pursuant to subdivision 5-d of section 2807-k of the Public Health Law shall be made in accordance with the provisions of this section. (1) Funds reserved in the Financial Assistance Compliance Pool (FACP) pursuant …

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.