N.Y. Comp. Codes R. & Regs. Tit. 10 § 86-4.35 - Computation of basic rates for clinic services provided to acquired immune deficiency syndrome (aids) and human immunodeficiency virus (hiv) sero-positive patients by freestanding ambulatory care facilities and hospital clinic outpatient services
(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 discrete price for each of the five
clinic services set forth in subdivision (c) of this section.
(b) To be eligible to receive reimbursement
pursuant to this section, facilities must be licensed pursuant to article 28 of
the Public Health Law and certified to provide general medical services and
complete a written signed agreement with the commissioner to provide these
discrete services. Facilities interested in establishing such agreements must
submit in writing the required documentation in a manner acceptable to the
commissioner. Such agreement shall describe the Medicaid patients who will be
eligible for reimbursement under this section and shall establish the
documentation and services required for patient assignment to each of the five
clinic services.
(c) The five
clinic services for which reimbursement shall be available according to the
prices as established by this section are as follows:
(1) HIV counseling and testing visits. This
visit shall mean the provision of pre-test HIV counseling in a medical setting
as performed in compliance with article 27-f of the State Public Health Law.
This visit shall also include laboratory testing necessary to determine whether
a person has HIV disease. This visit shall also mean the provision of post-test
HIV counseling in a medical setting as performed in compliance with the
confidentiality provisions of article 27-f of the State Public Health Law for
those individuals whose test results are positive. This visit is available for
the purpose of informing these individuals of their test results and providing
supportive counseling for those HIV zero positive persons experiencing adverse
psychological responses to their serostatus.
(2) Post-test counseling visit. This visit
shall mean the provision of post-test HIV counseling in a medical setting as
performed in compliance with the confidentiality provisions of article 27-f of
the State Public Health Law for those persons whose test results are negative.
This visit is available for the purpose of informing these individuals of their
results and counseling them on preventive measures.
(3) Initial comprehensive HIV medical
evaluation visit. This visit shall mean a comprehensive medical history and
physical examination, and laboratory testing necessary for the evaluation of
HIV disease and related conditions. The evaluation shall be complete enough to:
establish the state of HIV illness, diagnose active opportunistic infections
and tumors, identify appropriate prophylactic therapies to prevent future
opportunistic infections, initiate indicated anti-HIV therapy, and identify
significant psycho-social problems to be addressed in the care plan.
(4) Drug and immunotherapy visits for HIV
infected patients. This visit shall mean to those HIV-related treatments that
require active health care supervision during the treatment visit and/or
extensive amount of provider monitoring following the treatment.
(5) Monitoring visit for asymptomatic HIV
disease. This visit shall mean the clinical and laboratory evaluation necessary
to monitor the status of HIV disease to indicate the appropriate stage to
initiate active drug treatment for HIV or prophylactic treatment for
opportunistic infections.
(d) The prices established pursuant to this
section shall provide full reimbursement for the following:
(1) physician services, nursing services,
technician services, and other related professional expenses directly incurred
by the licensed facility;
(2) space
occupancy and plant overhead costs;
(3) administrative personnel, business
office, data processing, recordkeeping, housekeeping, and other related
facility overhead expenses;
(4) all
ancillary services including laboratory tests and diagnostic X-ray services
where specified in the treatment regimes and as detailed in the agreement
pursuant to subdivision (b) of this section; and
(5) all medical supplies, immunizations, and
drugs directly related to the provision of the services except for those drugs
used to treat AIDS patients for which fee for service reimbursement is
available under section 7.0 of the Medicaid Ordered Ambulatory Services Fee
Schedule as contained in the Medicaid Management Information Systems (MMIS)
Clinic Services Provider Manual (revised October, 1988). Copies of the schedule
may be obtained from the New York State Department of Social Services and are
available for inspection and copying at the Department of Health, Records
Access Office, 22nd Floor, Corning Tower Building, Governor Nelson A.
Rockefeller Empire State Plaza, Albany, New York 12237-0042.
(e) The price for each service
shall be adjusted for regional differences in wage levels, space occupancy and
facility overhead costs.
(f) The
commissioner shall establish trend factors to project increases in the base
year prices during the effective period of the reimbursement rates. The trend
factors shall be developed using available price indices including elements of
the United States Department of Labor consumer and producer price indices and
special price indices developed by the commissioner for this purpose. The
projected trend factors shall be updated on an annual basis, based upon current
and available data.
(g) At the
discretion of the commissioner, health services may be added or deleted from
the visits contained in subdivision (c) of this section. The commissioner shall
notify participating providers of such changes at least 60 days before such
changes shall be effective and the agreements as outlined in subdivision (b) of
this section shall be modified to encompass any such changes.
(h) Payment for any other clinic services
which are not covered pursuant to subdivision (c) of this section shall be
reimbursed as follows:
(1) for facilities
with a cost-based all inclusive clinic visit rate established pursuant to this
Subpart or to Subpart 86-1, services shall be reimbursed at the all inclusive
clinic visit rate.
(2) for
facilities without a cost-based all-inclusive rate, fee for service
reimbursement is available under the Ordered Ambulatory Services Fee Schedule
as referenced in paragraph (d)(5) of of this section for medical services
ordered by the patient's attending physician.
Notes
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