Part 86 Reporting and Rate Certifications for Facilities

(a) Errors resulting from submission of fiscal and statistical information by a LTHHCP may be corrected if brought to the attention of the State Commissioner of Health within 120 days of receipt of the commissioner's initial rate computation sheets. Errors on the part of the Stat…

(a) The State Commissioner of Health may consider only those applications for revisions of certified rates which are based on: (1) six-month cost reports filed pursuant to subdivision (e) of section 86-5.2 of this Subpart. Such rate shall become effective on the first day of the …

(a) This subdivision shall apply where the fiscal and statistical data of the facility are unavailable through no fault of the provider or its agents, and due to circumstances beyond its control, or where there is a new facility without adequate cost experience as set forth in se…

Reimbursement for the cost of providing services may be the lesser of the actual costs incurred or those costs which could reasonably be anticipated if such services had been provided by operation of joint central services or use of facilities or services which could have served …

(a) To be considered as allowable in determining reimbursement rates, costs shall be properly chargeable to necessary patient care. Except as otherwise provided in this Subpart, or in accordance with specific determination by the commissioner, allowable costs shall be determined …

(a) Operating costs shall be reduced by the costs of services and activities which are not properly chargeable to patient care. In the event that the Commissioner of Health determines that it is not practical to establish the costs of such services and activities, the income deri…

(a) Reported depreciation based on approved historical cost of buildings, fixed equipment and capital improvements made thereto is recognized as a proper element of cost for voluntary and public LTHHCPs. Useful lives shall be the higher of the reported useful life or those useful…

(a) Each LTHHCP shall complete and file, with the New York State Department of Health and/or its agent, annual financial and statistical report forms supplied by the department and/or its agent. LTHHCP certified for title XVIII of the Federal Social Security Act (Medicare) shall …

(a) Necessary interest on both current and capital indebtedness is an allowable cost for all LTHHCPs. (b) To be considered as an allowable cost, interest shall 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) Reimbursement for capital costs shall be allowable in determining rates for proprietary LTHHCPs. These costs shall be included as such costs are allocated from a related organization to the extent that: (1) those costs are reasonably related to the efficient production of lon…

(a) In computing the allowable costs of a proprietary LTHHCP, there shall be included a reasonable return on average equity capital. The percentage to be used in computing this allowance shall be a rate determined annually by the commissioner as reasonably related to the then cur…

Necessary and reasonable expenses related to movable equipment (depreciation computed on a straight-line method or accelerated under a double declining balance on sum-of-the-years-digits method, interest on indebtedness, lease, etc. pursuant to sections 86-5.17, 86-5.19, 86-5.20 …

(a) All research costs shall be excluded from allowable costs in computing reimbursement rates. (b) Research includes those studies and projects which have as their purpose the enlargement of general knowledge and understanding, are experimental in nature and hold no prospect of …

The costs of educational activities, less tuition and supporting grants, shall be included in the calculation of the basic rates, provided such activities are directly related to patient care services.

(a) The Division of Health Care Financing in the Department of Health 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 indic…

Payment for services provided by LTHHCPs certified as AHCPs shall be at rates established pursuant to this Subpart provided, however, that nursing services provided by any LTHHCP to patients diagnosed with Acquired Immune Deficiency Syndrome (AIDS) as defined by ICD-9 codes 042, …

(a) A related organization shall be defined as any entity which the LTHHCP is in control of or is controlled by, either directly or indirectly, or an organization, or institution whose actions or policies the LTHHCP has the power, directly or indirectly, to significantly influenc…

The direct costs for patient assessments and reassessments to the LTHHCP shall be included in the administrative costs of the LTHHCP and shall be included in the program's conversion of its cost report to an hourly or visit cost basis. These costs shall be limited to LTHHCP staff…

The completion of the financial and statistical report forms shall be in accordance with generally accepted accounting principles as applied to the LTHHCP, unless the reporting instructions authorize specific variation in such principles.

The financial and statistical reports shall be certified by an independent licensed public accountant or an independent certified public accountant.

(a) The financial and statistical reports shall be certified by the operator of a proprietary medical facility, an officer of a voluntary medical facility or the public official responsible for the operation of a public medical facility. (b) The form of the certification required…

(a) All fiscal and statistical records and reports shall be subject to audit. In this respect, any rate of payment certified by the State Commissioner of Health based on the initial submission of base-year data and reports will be construed to represent a provisional rate until s…

(a) A patient visit or an hourly rate are the units of measure by which an LTHHCP may bill for services provided. (b) Nursing, therapeutic and related services will be billed per visit. (c) Home health aides, personal care aides, homemaker and housekeeper services will be billed …

(a) At the time of the initial assessment, and at the time of each subsequent assessment performed for a long-term home health care program, or more often if the person's need requires it, the local social services district shall establish a monthly budget in accordance with whic…

As used in this Subpart, the following terms shall have the following meanings. (a) Hospice shall mean a hospice as defined in article 40 of the Public Health Law possessing a valid certificate of approval issued by the State Commissioner of Health. (b) A routine home care day is…

(a) Pursuant to 42 USC 1396a (a) (13)(D), rates of reimbursement for hospice shall be in amounts no lower than the amounts used under part A of title XVIII of the Social Security Act. Hospices may be eligible for supplemental rates of payment under the supplemental financial assi…

Reimbursement for attending and consulting physician services rendered to hospice patients shall be in accordance with the Medicaid fee schedule set forth in this title, as amended pursuant to chapter 904 of the Laws of 1984. The current fee schedule is set forth in section 7.0 o…

(a) Each hospice provider shall complete and file with the New York State Department of Health and/or its agent, financial and statistical reports as deemed necessary by the Commissioner of Health on forms supplied by the department. In instances where the hospice is a component …

(a) The commissioner shall establish trend factors to project annual increases in the costs of hospice services. Each payment rate for the categories of hospice care, as established pursuant to the provisions of section 86-6.2 of this Subpart, shall be trended each year by the tr…

(a) The supplemental financial assistance program provides enhanced payments to patients with special needs as defined in section 86-6.1(k) of this Subpart using payment rates established pursuant to section 86-6.2(g) of this Subpart. (b) To receive the enhanced Medicaid payment …

(a) Daily payment will be made to a hospice for Medicaid eligible patients who have elected the hospice benefit and reside in a nursing facility (see 42 USC 1396a[a][13][D]). Payment shall be made for a hospice patient to take into account the room and board furnished by the nurs…

As used in this Subpart, the following words shall have the following meanings: (a) Assisted living program shall mean an entity as defined in paragraph (a) of subdivision (1) of section 461-1 of the Social Services Law. (b) Services shall mean all services for which full payment…

(a) For each region, a rate of payment shall be established for each of the 16 patient classification groups. The rate of payment shall be established for the calendar year 1992. For each subsequent calendar year, the 1992 rate of payment shall be increased by a roll factor as de…

(a) For the calendar year 1992, for each region, the direct component as identified in section 86-7.2(b)(2) of this Subpart and the mean indirect price per day divided by the regional indirect input price adjustment factor for the patient classification group as identified in sec…

(a) This Subpart shall be effective if, and as long as, Federal financial participation is available for medical assistance expenditures made pursuant to this Subpart.

(a) This Subpart shall govern Medicaid rates of payments for ambulatory care services provided in the following categories of facilities for the following periods: (1) outpatient services provided by general hospitals on and after December 1, 2008; (2) emergency department servic…

Payments for the following shall be excluded from rates set pursuant to this Subpart: (a) Drugs and other pharmaceutical products and implantable family planning devices for which separate and distinct outpatient billing and payment were authorized by the department as of Decembe…

(a) the following elements of the APG rate-setting system shall be updated no less frequently than annually: (1) the listing of reimbursable APGs subject to this Subpart and the relative weight assigned to each such APG; (2) the base rates; (3) the applicable ICD-9 codes utilized…

for visits occurring on and after January 1, 2009, by hospital outpatient clinics and diagnostic and treatment centers otherwise subject to this Subpart, which are scheduled and occur on evenings, weekends and holidays as defined by the department, a supplemental APG payment amou…

(a) Rates for services specified in section 86-8.1(a) of this Subpart provided in outpatient facilities located outside New York state shall be as follows: (1) rates in effect for similar services for providers located in the downstate region of New York State shall apply with re…

To the extent authorized pursuant to section 2807(2-a) of the Public Health Law, payments for individual psychotherapy services provided by clinical social workers, as defined by section 86-4.9 of this Subpart, shall be established at $40.64 for encounters lasting between 20 and …

(a) The commissioner may grant approval of a temporary adjustment to the non-capital components of rates calculated pursuant to this Subpart for eligible ambulatory care facilities licensed under article 28 of the Public Health Law (PHL). (b) Eligible facilities shall include: (1…

As used in this Subpart, the following definitions shall apply: (a) Ambulatory patient group (APG) shall mean a defined group of outpatient procedures, encounters or ancillary services, as specifically identified and published by the department, which reflect similar patient char…

(a) General hospitals whose rates of payments are governed by this Subpart shall: (1) continue to maintain financial and statistical data and records in accordance with otherwise applicable statutes and regulations, including, but not limited to, regulations as set forth in Subpa…

(a) A capital cost component shall be added to Medicaid payments made pursuant to this Subpart and computed in accordance with the following: (1) the computation of the capital cost component for payments for general hospital outpatient and emergency services shall remain subject…

(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 published by the department to the facility. Such rate appeals must set forth in detail the basis for such…

(a) General hospital outpatient clinics which commence operation after December 31, 2007 and prior to January 1, 2012, and for which rates computed pursuant to Public Health Law section 2807(2) are not available shall have the capital cost component of their rates based on a budg…