Outpatient Services Licensed Under the Mental Hygiene Law

SUMMARY OF PROPOSED RULE MAKING Outpatient Services Licensed Under the Mental Hygiene Law

This proposed rulemaking creates a regulation for establishing rate reductions for exceeding utilization thresholds beginning on or after April 1, 2011 for OHM, OASAS, and OPWDD certified clinics based on annual patient visits in each state fiscal year. This regulation is required per the Laws of 2011, Chapter 59, part H, sections 26 and 111(a).

UTILIZATION LIMITS ON OMH LICENSED CLINICS Rate reductions will be applied to OMH licensed clinics as follows. Off-site visits, medical visits, and crises visits, when billed under their applicable rate codes, shall be disregarded in computing the number of visits.

For persons aged 21 or older with total number of visits in state fiscal year of: 0 – 30 visits No rate reduction 31 – 50 visits 25% rate reduction Over 50 visits 50% rate reduction

For persons less than 21 years of age with total number of visits in state fiscal year of: 0 – 50 visits No rate reduction Over 50 visits 50% rate reduction

UTILIZATION LIMITS ON OASAS LICENSED CLINICS Rate reductions will be applied to OASAS licensed clinics for Medicaid payments as follows for the total number of visits in state fiscal year.

0 – 75 visits No rate reduction 76 – 95 visits 25% rate reduction Over 95 visits 50% rate reduction

UTILIZATION LIMITS ON OPWDD LICENSED CLINICS Rate reductions will be applied to OPWDD licensed clinics as follows. For the period April 1, 2011 through March 31, 2012, OPWDD may waive the reimbursement rate reductions if the clinic submits a request for a waiver and a utilization reduction plan.

Monthly utilization thresholds are set for specific service category as: (i) Nutrition/dietetics: 2.08 (ii) Speech language pathology: 4.33 (iii) Occupational therapy: 4.08 (iv) Physical therapy: 5.25 (v) Rehabilitation counseling: 3.25 (vi) Individual psychotherapy: 3.08 (vii) Group psychotherapy: 3.17

For each service category identified above, OPWDD will annually calculate a monthly utilization rate for each clinic based on paid Medicaid claims for services rendered during the utilization review period. Visits associated with patients who received fewer than four visits within a service category shall be excluded from monthly utilization rate calculations.

When a clinic's calculated monthly utilization rate exceeds the monthly utilization threshold, OPWDD will calculate ‘‘excess visits’’ based on the following formula: Excess Visits = (Clinic monthly utilization rate - Threshold Value) * Recipient Months

OPWDD will sum a clinic's excess visits across all service categories. OPWDD will calculate excess visits as a percentage of total paid visits during the utilization review period. The reimbursement rates of clinics with excess visits shall be reduced by a uniform percentage as follows:

Excess Visits as a percentage of Total Paid Visits Reduction 15.1% or more 5.00% Between 10.1% and 15% 4.25% Between 5.1% and 10% 3.50% Between 1% and 5% 2.75% Less than 1% 0.00%