Part 86 Reporting and Rate Certifications for Facilities

(a) Except as specifically identified in subdivision (g), rates for residential health care facility services for adult day health care registrants shall be computed on the basis of the allowable costs, as reported by the residential health care facility, and the total number of …

As used in this Subpart, health maintenance organization or HMOmeans any entity or entities providing a comprehensive prepaid health service plan(s) certified under article 44 of the Public Health Law. IX-C rate refers to individual hospital rates promulgated by IX-C hospital ser…

The purpose of this Subpart is to implement the legislative requirement that the Commissioner of Health approve rates to be paid by article 44 HMO's to hospitals for inpatient services.

Hospitals certified under article 28 of the Public Health Law may not deny admission solely on grounds of HMO membership. This section applies to the general prepaid membership of an HMO; Medicare and Medicaid reimbursement for such services shall be as described in subdivision (…

Implementation of these regulations shall be based on the following: (a) No written agreement between hospital and HMO is required to initiate and continue this reimbursement methodology. (b) Upon request by the HMO, a hospital shall furnish documentation of the certified IX-C ra…

(a) Pursuant to section 2807-c(2-a) of the Public Health Law, health maintenance organizations certified under article 44 of the Public Health Law or article 43 of the Insurance Law shall pay a nine percent differential on their rates of payment for general hospital inpatient ser…

As used in this Subpart: (a) Facility shall mean all free-standing ambulatory care facilities, diagnostic and/or treatment centers and clinics that are subject to article 28 of the Public Health Law, provided that such facility has been established by the Public Health Council an…

(a) For the purpose of determining the number of threshold visits to be used in the computation of basic rates, the commissioner shall establish minimum utilization standards as provided in this section. Such standards shall be based upon an assessment of visits per full-time equ…

(a) Rates of payment for facilities other than licensed free-standing ambulatory surgery centers shall be established on a prospective basis and shall be computed on the basis of allowable fiscal and statistical data submitted by the facility for the fiscal year ended at least 15…

(a) Basic rates of payment by governmental agencies for voluntary nonprofit or publicly sponsored diagnostic and/or treatment centers which provide a comprehensive range of primary health care services and can demonstrate losses as a result of providing a disproportionate share o…

(a) For the purpose of establishing reimbursable operating costs, facilities shall be compared on the basis of the following general criteria: (1) similarity of services; and (2) regional economic factors. (b) Comparisons using similarity of services shall be based on the followi…

(a) Reimbursement rate ceilings for the administrative cost center, the patient transportation cost center and for comparable patient care cost centers shall be established for facilities. Comparable patient care cost centers shall include, but not be limited to, the following: (…

(a) The commissioner shall establish trend factors to project increases in allowable operating costs during the effective period of the reimbursement rate. (b) To determine trend factors, the elements of facilities' costs shall be weighted based upon data for salaries, employee h…

(a) The commissioner shall consider only those applications for prospective revisions of certified or approved rates which are in writing and which address one or more of the issues set forth in this section. (b) Errors, whether mathematical or clerical, made by the department or…

(a) An application by a facility for review of a certified or approved rate pursuant to section 86-4.16 of this Subpart shall be submitted to the bureau for staff review and shall set forth the basis for the appeal and the issues of fact. Documentation shall accompany the applica…

(a) A facility shall be deemed to be without adequate cost experience when fiscal and statistical data necessary for setting a rate are unavailable through no fault of the operator or his or her agents, and due to circumstances beyond his or her control, or in the instance of a n…

(a) Computation of rates of payment for facility services by government agencies and article 43 corporations shall be governed by the provisions of this Subpart. (b) Each article 43 corporation shall submit a proposed reimbursement formula not inconsistent with the rules set fort…

The capital cost of a facility for purposes of determining and certifying the capital cost component of a rate shall be determined and computed in accordance with the provisions of sections 86-4.23 through 86-4.26 of this Subpart, and shall be certified and audited as actually ha…

(a) To be considered as allowable in determining reimbursement rates, costs must be actual, reasonable and properly chargeable to necessary patient care. Except as otherwise provided in this Part, or in accordance with specific determination by the commissioner, allowable costs s…

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 commissioner determines that it is not practical to establish the costs of such services and activities, the income derived from them m…

(a) Allowable depreciation shall be limited to those assets which are used for purposes of providing or supporting direct patient care. Reported depreciation based on historical cost is recognized as a proper element of cost. Useful lives for assets purchased after 1991 shall be …

(a) Necessary interest on both current and capital indebtedness is an allowable cost for all facilities. (b) To be considered an allowable cost, interest must be incurred to satisfy a financial need, and at a rate not in excess of what a prudent borrower would have had to pay in …

(a) In computing the allowable costs of a proprietary facility, there shall be included an allowance for a reasonable return on the average equity capital representing the owner's investment for the provisions of patient care. The percentage to be used in computing the allowance …

(a) If a facility is sold or leased or is the subject of any other realty transaction before a rate for the facility has been determined and certified by the commissioner, the capital cost component of such rate shall be determined in accordance with the provisions of sections 86…

(a) Reasonable compensation for operators or relatives of operators for required services actually performed shall be considered 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 emp…

(a) A related organization shall be defined as any entity which controls the facility or which the facility controls, either directly or indirectly, or an organization or institution whose actions or policies the facility has the power, directly or indirectly, to significantly in…

(a) Effective for all fiscal years beginning on or after January 1, 1975 treatment centers and/or diagnostic centers shall use the accrual basis of accounting except where an alternate basis is mandated by law. For fiscal years beginning on or after January 1, 1986 treatment cent…

The bureau shall be notified within 30 days of the deletion of any previously offered service or if services are withheld from patients paid for by any government agency. Such notification shall include a statement indicating the date of the deletion or withholding of the service…

(a) The commissioner may waive the requirements of this Subpart to effect the development of additional knowledge and experience in different types of reimbursement mechanisms, contingent upon the approval of the United States Department of Health and Human Services where necessa…

(a) For payments made pursuant to this section and pursuant to section 86-1.11(h) of this Part, for ambulatory services to AIDS patients, HIV positive patients, and patients seeking verification of HIV infection, reimbursement shall be based upon a single payment schedule with a …

(a) For payments made pursuant to this section and pursuant to section 86-1.11(h) of this Part, for ambulatory care services to Medicaid patients, reimbursement shall be based upon a uniform payment schedule with a discrete price set forth in subdivision (c) of this section. (b) …

(a) Notwithstanding other provisions of this Subpart or Subpart 86-1, rates of reimbursement for specialty services, including but not limited to hemo and peritonial dialysis and outpatient rehabilitative services, shall be calculated in the manner described in section 86-4.37(a)…

(a) For payments made pursuant to this section and pursuant to section 86-1.11(h)(5) of this Part, for methadone maintenance treatment services reimbursement shall be based upon a fixed weekly payment per recipient. (b) To be eligible to receive reimbursement pursuant to this sec…

(a) All financial and statistical reports shall be certified by an independent licensed public accountant or an independent certified public accountant on forms prescribed and provided by the department. A copy of the audited financial statements shall accompany the financial and…

(a) Medicaid reimbursement for ambulatory surgery services provided by licensed free-standing ambulatory surgical centers and hospital-based ambulatory surgery services shall be based upon a single payment schedule with a discrete price for each of the separate groupings of surgi…

Computation of basic rates for day health care services provided by freestanding ambulatory care facilities to patients with acquired immune deficiency syndrome (AIDS), other human immunodeficiency virus (HIV) related illnesses and other high-need populations that, regardless of …

(a) In the event that any information or data which a facility has submitted to the department for use in establishing rates is found by the facility to be incorrect or incomplete for any reason, the facility shall submit corrected and complete information or data to the departme…

(a) All fiscal and statistical records and reports shall be subject to audit, which must commence no later than six years from the date of filing or the date when due, whichever is later. There shall be no limitation in situations involving possible fraud or where the facility or…

Any facility eligible for title XVIII (Medicare) certification providing services to patients insured under title XIX which is not, or ceases to be, a title XVIII provider of care shall have its current reimbursement rate reduced by 10 percent. This rate reduction may remain in e…

(a) The unit of service used to establish rates of payment shall be the threshold visit, except for dialysis, abortion, sterilization services and free-standing ambulatory surgery, for which rates of payment shall be established for each procedure. For methadone maintenance treat…

As used in this Subpart: (a) The term long-term home health care program (LTHHCP)shall mean an organization defined in article 36 of the Public Health Law possessing a valid operating certificate or valid certificate of approval issued by the State Commissioner of Health to opera…