§ 2807 — Hospital reimbursement provisions; generally

New York § 2807

• Jurisdiction: New York
• Law PBH: Public Health
• Art. 28: Hospitals

Text

§ 2807. Hospital reimbursement provisions; generally. 1. Valid\noperating certificate requirement. No government agency and no\ncorporation organized and operating in accordance with article\nforty-three of the insurance law and no health maintenance organization\norganized and operating in accordance with article forty-four of this\nchapter, shall purchase, pay for or make reimbursement or grants-in-aid\nfor any hospital or health-related service, unless, at the time the\nservice was provided, the hospital possessed a valid operating\ncertificate authorizing such service. No government agency shall\npurchase, pay for or make reimbursement or grants-in-aid for any\nhospital or health-related service that has been determined by the\ncommissioner of health to be unauthorized for payment under the medical\nassistance program pursuant to section twenty-eight hundred three of\nthis article.\n 2. (a) Rate approvals. Payments for hospital service and\nhealth-related service made by government agencies or for services\nprovided prior to January first, nineteen hundred ninety-seven by\norganizations operating in accordance with the provisions of article\nforty-four of this chapter shall be at rates approved by the state\ndirector of the budget in the case of government agencies and approved\nby the commissioner in the case of plans, organized and operating under\nthe provisions of article forty-four of this chapter, under which such\npayments are made by agencies other than government agencies or\ncorporations organized and operating in accordance with article\nforty-three of the insurance law. Payments for hospital service and\nhealth-related service by corporations organized and operating in\naccordance with article forty-three of the insurance law for services\nprovided prior to January first, nineteen hundred ninety-seven shall be\nat rates approved by the commissioner of health.\n (a-1) Notwithstanding any inconsistent provision of law, rates of\npayment by governmental agencies for the operating cost component of\ngeneral hospital out-patient and emergency services, and for the\noperating cost component of treatment or diagnostic center services\nshall not require a certification by the commissioner that they are\nreasonably related to the costs of efficient production of such services\nnor that they are reasonable and adequate to meet the costs which must\nbe incurred by efficiently and economically operated facilities.\n (b) During the period October first, nineteen hundred ninety-four\nthrough September thirtieth, nineteen hundred ninety-five and for each\ntwelve month rate period commencing on October first thereafter, rates\nof payment by governmental agencies for the operating cost component of\ntreatment or diagnostic center services shall be based on operating\ncosts in the base year cost report adjusted by a trend factor determined\nin accordance with rules and regulations promulgated pursuant to\nparagraph (b) of subdivision two of section twenty-eight hundred three\nof this article; provided, however, that prior to such adjustment,\nallowable operating costs shall be established by the commissioner after\ntaking into account the cost of services provided in facilities offering\nsimilar services and regional economic factors, plus the addition of the\ncapital cost per visit. The capital cost per visit shall be based on the\nbase year cost report except that the capital cost per visit may be\nadjusted for major outpatient capital expenditures, incurred subsequent\nto the reporting year, when such expenditures have received the\nrequisite approvals and the facility has provided the commissioner with\na certified statement of expenditures. The base year for the rate period\ncommencing on October first, nineteen hundred ninety-four shall be\nnineteen hundred ninety-two and shall be advanced one year thereafter\nfor each subsequent rate period.\n (c) Notwithstanding any other provision of law to the contrary, for a\ndiagnostic and treatment center licensed pursuant to this article that\nprovides, as its principal mission, services to individuals with\ndevelopmental disabilities, the commissioner may fully or partially\nwaive or modify recoupment of medical assistance payments based on\nretroactive changes to the applicable formula for capital costs for the\nperiod of September first, two thousand nine to December thirty-first,\ntwo thousand twelve.\n * (e) Notwithstanding any inconsistent provisions of this subdivision\nor any other law, payments made by governmental agencies for ambulatory\nsurgical services provided by a hospital, including general hospitals\nand diagnostic and treatment centers, during the period June first,\nnineteen hundred eighty-nine through December thirty-first, nineteen\nhundred eighty-nine and the period January first, nineteen hundred\nninety through December thirty-first, nineteen hundred ninety and every\ntwelve month rate period thereafter shall be at case based rates of\nreimbursement established by the commissioner and approved by the state\ndirector of the budget. Ambulatory surgical services case based rates of\npayment shall be established prospectively and shall include operating\ncosts and capital costs. Factors considered in establishing such case\nbased rates shall include, but not be limited to: a classification of\nprocedures with individual or combined rates established for each\nservices classification; operating and capital costs of ambulatory\nsurgical services efficiently and economically provided, considering\nregional economic factors, trended to the rate period; and the need for\nincentives to improve services and institute economies.\n * NB Expired April 1, 2011\n * (f) (i) During the period July first, nineteen hundred ninety\nthrough March thirty-first, nineteen hundred ninety-one, the rate\nperiods during the period April first, nineteen hundred ninety-one\nthrough September thirtieth, nineteen hundred ninety-four and for each\nfiscal year period commencing on October first thereafter, comprehensive\nclinic rates of payment by governmental agencies established in\naccordance with paragraph (b) of this subdivision, applicable for\nservices provided to individuals eligible for medical assistance\npursuant to title eleven of article five of the social services law for\nvoluntary non-profit or publicly sponsored diagnostic and treatment\ncenters providing a comprehensive range of primary health care services\nwhich can demonstrate, on forms provided by the commissioner, losses\nfrom a disproportionate share of bad debt and charity care during a base\nyear period established by regulation may include an allowance\ndetermined in accordance with this paragraph to reflect the needs of the\ndiagnostic and treatment center for the financing of losses resulting\nfrom bad debt and the costs of charity care. Losses resulting from bad\ndebt and the costs of charity care shall be determined by the\ncommissioner considering, but not limited to, such factors as the losses\nresulting from bad debt and the costs of charity care provided by the\ndiagnostic and treatment center and the availability of other financial\nsupport, including state and local assistance public health aid, to meet\nthe losses resulting from bad debt and the costs of charity care of the\ndiagnostic and treatment center. The bad debt and charity care allowance\nfor a diagnostic and treatment center for a rate period shall be\ndetermined by the commissioner in accordance with rules and regulations\nadopted by the council and approved by the commissioner, and shall be\nconsistent with the purposes for which such allowances are authorized\nfor general hospitals pursuant to the provisions of article twenty-eight\nof this chapter and rules and regulations promulgated by the\ncommissioner. A diagnostic and treatment center applying for a bad debt\nand charity care allowance pursuant to this paragraph shall provide\nassurances satisfactory to the commissioner that it shall undertake\nreasonable efforts to maintain financial support from community and\npublic funding sources and reasonable efforts to collect payments for\nservices from third party insurance payors, governmental payors and\nself-paying patients. To be eligible for an allowance pursuant to this\nparagraph, a diagnostic and treatment center must provide a\ncomprehensive range of primary health care services and must demonstrate\nthat a minimum of fifteen percent of total clinic visits reported during\nthe applicable base year period were to uninsured individuals. The\ncommissioner may retrospectively reduce the bad debt and charity care\nallowance of a diagnostic and treatment center if it is determined that\nprovider management actions or decisions have caused a significant\nreduction for the rate period in the delivery of comprehensive primary\nhealth care services to bad debt and charity care residents of the\ncommunity.\n (ii) The total amount of funds to be allocated and distributed for bad\ndebt and charity care allowances to eligible voluntary and nonprofit\ndiagnostic and treatment centers for a rate period in accordance with\nthis paragraph shall be limited to an annual aggregate amount of seven\nmillion three hundred thousand dollars. The total amount of funds to be\nallocated and distributed for bad debt and charity care allowances to\neligible publicly sponsored diagnostic and treatment centers for a rate\nperiod in accordance with this paragraph shall be limited to an annual\naggregate amount of seven million seven hundred thousand dollars;\nprovided, however, that twenty percent of the amount of funds allocated\nfor distribution to eligible publicly sponsored diagnostic and treatment\ncenters shall be available for clinics operating under the auspices of\nthe Health and Hospitals Corporation. Notwithstanding the foregoing and\nany other provision of this chapter municipalities which received state\naid, pursuant to article two of the public health law and prior to the\neffective date of this chapter, in support of non-hospital based\nfree-standing or local health department operated general medical\nclinics, shall receive a bad debt and charity care allowance of not less\nthan the amount received in the nineteen hundred eighty-nine--nineteen\nhundred ninety state fiscal year for general medical clinics, plus the\napplicable local share for medical assistance expenditures under title\nXIX of the federal social security act. Funds to be distributed pursuant\nto this subparagraph shall be based on losses associated with the\ndelivery of bad debt and charity care excluding the amount of such\nlosses determined in accordance with subparagraph (ix) of this paragraph\nas the incremental loss basis for a supplemental allowance for a\ndiagnostic and treatment center designated as a preferred primary care\nprovider.\n (iii) No diagnostic and treatment center may receive a bad debt and\ncharity care allowance in accordance with this paragraph in an amount\nwhich exceeds its need for the financing of losses associated with the\ndelivery of bad debt and charity care.\n (iv) A nominal payment amount for the financing of losses associated\nwith the delivery of bad debt and charity care will be established for\neach eligible diagnostic and treatment center. The nominal payment\namount shall be calculated as the sum of the dollars attributable to the\napplication of an incrementally increasing nominal coverage percentage\nof base year period losses associated with the delivery of bad debt and\ncharity care for percentage increases in the relationship between base\nyear period eligible bad debt and charity care clinic visits and base\nyear period total clinic visits according to the following scale:\n% of eligible bad debt and charity care % of nominal financial\n clinic visits to total visits loss coverage\n up to 15% 50%\n 15 - 30% 75%\n 30%+ 100%\nIf the sum of the nominal payment amounts for all eligible voluntary\nnon-profit diagnostic and treatment centers or for all eligible public\ndiagnostic and treatment centers is less than the amount allocated for\nbad debt and charity care allowances pursuant to subparagraph (ii) or\n(ix) respectively of this paragraph for such diagnostic and treatment\ncenters respectively, the nominal coverage percentages of base year\nperiod losses associated with the delivery of bad debt and charity care\npursuant to this scale may be increased to not more than one hundred\npercent for voluntary non-profit diagnostic and treatment centers or for\npublic diagnostic and treatment centers in accordance with rules and\nregulations adopted by the council and approved by the commissioner.\n (v) The bad debt and charity care allowance for each eligible\nvoluntary non-profit diagnostic and treatment center shall be based on\nthe dollar value of the result of the ratio of total funds allocated for\nbad debt and charity care allowances for voluntary non-profit diagnostic\nand treatment centers pursuant to subparagraph (ii) of this paragraph to\nthe total statewide nominal payment amounts for all eligible voluntary\nnon-profit diagnostic and treatment centers determined in accordance\nwith subparagraph (iv) of this paragraph applied to the nominal payment\namount for each such diagnostic and treatment center.\n (vi) The bad debt and charity care allowance for each eligible public\ndiagnostic and treatment center shall be based on the dollar value of\nthe result of the ratio of total funds allocated for bad debt and\ncharity care allowances for public diagnostic and treatment centers\npursuant to subparagraph (ii) of this paragraph to the total statewide\nnominal payment amounts for all eligible public diagnostic and treatment\ncenters determined in accordance with subparagraph (iv) of this\nparagraph applied to the nominal payment amount for each such diagnostic\nand treatment center.\n (vii) Diagnostic and treatment centers shall furnish to the department\nsuch reports and information as may be required by the commissioner to\nassess the cost, quality, access to, effectiveness and efficiency of bad\ndebt and charity care provided. The council shall adopt rules and\nregulations, subject to the approval of the commissioner, to establish\nuniform reporting and accounting principles designed to enable\ndiagnostic and treatment centers to fairly and accurately determine and\nreport bad debt and charity care visits and the costs of bad debt and\ncharity care. In order to be eligible for an allowance pursuant to this\nparagraph, a diagnostic and treatment center must be in compliance with\nbad debt and charity care reporting requirements.\n (viii) Of the funds allocated and distributed for bad debt and charity\ncare allowances to eligible voluntary and non-profit diagnostic and\ntreatment centers for a rate period in accordance with subparagraph (ii)\nof this paragraph, an annual aggregate amount not to exceed three\nmillion eight hundred thousand dollars within a rate period shall be\npaid by or on behalf of diagnostic and treatment centers into a primary\ncare initiative pool established by the commissioner. Such funds shall\nbe distributed to diagnostic and treatment centers in accordance with\nthe provisions of subdivisions one through six of section twenty-eight\nhundred seven-b of this article.\n (ix) During the period January first, nineteen hundred ninety-four\nthrough September thirtieth, nineteen hundred ninety-four and for each\ntwelve month rate period commencing on October first thereafter, to the\nextent of funds available therefor, a diagnostic and treatment center\nwhich is approved as a preferred primary care provider pursuant to\nsubdivision twelve of section twenty-eight hundred seven of this article\nand meets the requirements of this paragraph may be eligible for a\nsupplemental allowance determined in accordance with this paragraph. The\nsupplemental allowance shall be based on losses associated with the\ndelivery of bad debt and charity care incurred by a preferred primary\ncare provider to the extent such losses exceed any losses associated\nwith the delivery of bad debt and charity care incurred for nineteen\nhundred ninety-three or, if later, the year immediately preceding the\nyear in which the diagnostic and treatment center is first designated a\npreferred primary care provider.\n (x) This paragraph shall be effective if, and as long as, federal\nfinancial participation is available for expenditures made for\nbeneficiaries eligible for medical assistance under title XIX of the\nfederal social security act based upon the allowances determined in\naccordance with this paragraph.\n (xi) Notwithstanding any inconsistent provision of this paragraph,\nadjustments to rates of payment for diagnostic and treatment centers\ndetermined in accordance with subparagraphs (i) through (x) of this\nparagraph shall apply only for services provided on or before December\nthirty-first, nineteen hundred ninety-six.\n * NB Expired December 31, 1996\n (g)(i) During the period April first, nineteen hundred ninety-four\nthrough December thirty-first, nineteen hundred ninety-four and for each\ncalendar year rate period commencing on January first thereafter, rates\nof payment by governmental agencies for the operating cost component of\ngeneral hospital outpatient services shall be based on the operating\ncosts reported in the base year cost report adjusted by the trend factor\napplicable to the general hospital in which the services were provided;\nprovided, however, that the maximum payment for the operating cost\ncomponent of outpatient services shall be sixty-seven dollars and fifty\ncents plus the addition of the capital cost per visit. The capital cost\nper visit shall be based on the base year cost report except that the\ncapital cost per visit may be adjusted for major outpatient capital\nexpenditures incurred subsequent to the reporting year, when such\nexpenditures have received the requisite approvals and the facility has\nprovided the commissioner with a certified statement of the\nexpenditures. The base year for the period April first, nineteen hundred\nninety-four through December thirty-first, nineteen hundred ninety-four\nshall be nineteen hundred ninety-two and shall be advanced one year\nthereafter for each subsequent calendar year rate period. Further, the\nprovisions of subdivision seven of this section shall not apply. The\ncommissioner may waive the maximum allowable payment and limitations on\nthe rate of payment as prescribed herein to provide for the\nreimbursement of offering and arranging services eligible for ninety\npercent federal funds as set forth in section nineteen hundred three of\nthe federal social security act, and to provide for the reimbursement of\nspecialized services having separately identifiable costs and\nstatistics, including but not limited to hemodialysis services and\nsurgical services provided on an outpatient basis. Such waiver shall be\ngranted only when the commissioner finds that the services are being\nprovided efficiently and at minimum cost. The commissioner shall\npromptly promulgate rules and regulations necessary to identify such\nservices. Among the criteria which the commissioner shall consider in\nthe case of specialized services are whether the services require highly\nspecialized staff, equipment or facilities, thereby generating a cost\nthat substantially exceeds that of more routine diagnostic or treatment\nservices; whether the facility in which the services are provided is\npresently providing the services to the population in need; and, whether\nthe services may be provided safely and effectively on an outpatient\nbasis at a lower cost than through inpatient admission. In addition the\ncommissioner shall provide for a waiver of the maximum allowable payment\nfor those outpatient services medically necessary which include surgical\nprocedures where delay in surgical intervention would substantially\nincrease the medical risk associated with such surgical intervention.\nWhere the commissioner waives the maximum allowable payment for any\nspecified service he may, in accordance with the foregoing criteria and\nsuch other criteria as he deems appropriate, establish a maximum\nallowable payment for such specified service.\n (ii) During the period April first, nineteen hundred ninety-four\nthrough December thirty-first, nineteen hundred ninety-four and for each\ncalendar year rate period commencing on January first thereafter, rates\nof payment by governmental agencies for the operating cost component of\ngeneral hospital emergency services shall be based on the operating\ncosts reported in the base year cost report adjusted by the trend factor\napplicable to the general hospital in which the services were provided,\nand in addition shall include that portion of the reasonable incremental\nemergency service operating costs incurred by such hospital in excess of\nemergency service costs reported in the nineteen hundred eighty-eight\ncost report, after application of the trend factor, attributable to\nmeeting additional quality of care standards for emergency services that\nbecame effective on or after January first, nineteen hundred\neighty-nine; provided, however, that the maximum payment for the\noperating component shall be ninety-five dollars, provided further,\nhowever, that for the period January first, two thousand seven through\nDecember thirty-first, two thousand seven the maximum payment for the\noperating component shall be one hundred twenty-five dollars, and during\nthe period January first, two thousand eight through December\nthirty-first, two thousand eight, the maximum payment for the operating\ncomponent shall be one hundred forty dollars; and during the period\nJanuary first, two thousand nine through December thirty-first, two\nthousand nine and for each calendar year thereafter, the maximum payment\nfor the operating component shall be one hundred fifty dollars. A\ncapital cost per visit shall be based on the base year cost report\nexcept that the capital cost per visit may be adjusted for the major\noutpatient capital expenditures incurred subsequent to the report year,\nwhen such expenditures have received the requisite approvals and the\nfacility has provided the commissioner with a certified statement of\nexpenditures. The base year for the period April first, nineteen hundred\nninety-four through December thirty-first, nineteen hundred ninety-four\nshall be nineteen hundred ninety-two and shall be advanced one year\nthereafter for each subsequent calendar year rate period. Further, the\nprovisions of subdivision seven of this section shall not apply prior to\nJanuary first, two thousand seven.\n * (iii) (A) For purposes of this subparagraph:\n (1) "Children with medical fragility" shall mean an individual who is\nunder twenty-one years of age and has a chronic debilitating condition\nor conditions, who may or may not be hospitalized or institutionalized,\nand who meets one or more of the following criteria: (I) is\ntechnology-dependent for life or health sustaining functions; (II)\nrequires complex medication regimens or medical interventions to\nmaintain or to improve their health status; or (III) is in need of\nongoing assessment or intervention to prevent serious deterioration of\ntheir health status or medical complications that place their life,\nhealth or development at risk.\n (2) "Pediatric residential health care facility" shall mean a\nfree-standing facility or discrete unit within a facility authorized by\nthe commissioner to provide extensive nursing, medical, psychological,\nand counseling support services solely to children under the age of\ntwenty-one.\n (3) "Pediatric diagnostic and treatment center" shall mean a\ndiagnostic and treatment center established pursuant to this article,\nwhich as of April first, two thousand twenty-four, has been\nparticipating in the demonstration program authorized under subdivision\none of section twenty-eight hundred eight-e of this article, for which\nat least eighty percent of its total Medicaid fee-for-service\nreimbursements derive from the provision of services to children under\nthe age of twenty-one with medical fragility and is affiliated with a\npediatric residential health care facility.\n (B) (1) Notwithstanding any law, rule, or regulation to the contrary,\nthe commissioner shall establish rates of reimbursement for pediatric\ndiagnostic and treatment centers for all services provided on or after\nApril first, two thousand twenty-four, to children eligible for medical\nassistance that reflect the costs necessary to provide care and services\nto children with medical fragility being treated at such pediatric\ndiagnostic and treatment center.\n (2) For the period April first, two thousand twenty-four, to December\nthirty-first, two thousand twenty-four, and until such time as a\ncertified annual cost report for such period is received and verified by\nthe department, the operating component of such rate shall reflect\nbudgeted costs for the period January first, two thousand twenty-four,\nthrough December thirty-first, two thousand twenty-four, as submitted to\nthe department and adjusted as the commissioner deems appropriate. Upon\nsubmission and subsequent verification of the cost report, the operating\ncomponent of the rate shall be reflective of actual costs for the period\nJanuary first, two thousand twenty-four, through December thirty-first,\ntwo thousand twenty-four, subject to further adjustments as the\ncommissioner deems appropriate. Thereafter, the base period reported\noperating costs used to establish rates pursuant to this subparagraph\nshall be updated no less frequently than every two years. In addition to\nrequired annual cost reports, pediatric diagnostic and treatment\ncenters, as defined by this subparagraph, shall submit additional data\nas the commissioner requires.\n (3) Notwithstanding any law, rule, or regulation to the contrary,\npediatric diagnostic and treatment centers shall be reimbursed for\nservices provided to children enrolled in Medicaid managed care plans at\nthe rates of reimbursement promulgated pursuant to this subparagraph.\n (4) The capital component of the rate shall reflect actual base year\ncosts.\n (5) All rates established under this subparagraph shall be subject to\nthe availability of federal financial participation.\n (6) The commissioner may promulgate or amend regulations as the\ncommissioner determines appropriate and necessary to establish the rates\nprovided for in this subparagraph and/or exempt pediatric diagnostic and\ntreatment centers from the ambulatory payment group reimbursement\nmethodology applicable to diagnostic and treatment centers.\n * NB Repealed April 1, 2027\n (h) Notwithstanding any inconsistent provisions of this subdivision or\nany other law, except as provided in section 43.02 of the mental hygiene\nlaw, the commissioner may, in accordance with rules and regulations\nadopted by the council and approved by the commissioner, establish rates\nof reimbursement for payments made by governmental agencies, subject to\nthe approval of the state director of the budget, for services provided\non an outpatient basis by a general hospital or diagnostic and treatment\ncenter designated as a preferred primary care provider pursuant to\nsubdivision twelve of this section or providing specialty services\nincluding hemo and peritoneal dialysis, outpatient rehabilitative and\npsychiatric services, methadone maintenance, and other organized\noutpatient or clinic services which are structured to address extensive\nand complex medical needs for patients with chronic or infectious\nmedical conditions based on factors other than those prescribed by\nparagraph (b) or subparagraph (i) of paragraph (g) of this subdivision\nor subdivision three of this section provided, however, that the use of\nsuch an alternative approach will not result in any increase to other\nrates of reimbursement established pursuant to this article. During the\ninitial rate period such rates of payment for preferred primary care\nproviders shall be at least equal to the average rate of payment per\nvisit which would otherwise be provided pursuant to subparagraph (i) of\nparagraph (g) or paragraph (b) of this subdivision. Factors used to\nestablish rates shall include a reasonable classification of medical\nprocedures with individual or combined rates established for each\nservice classification group which will be prospectively determined\nbased upon an estimate of the costs of such outpatient services\nefficiently and economically provided by general hospitals and\ndiagnostic and treatment centers, considering regional economic factors\nand the need for incentives to improve services and institute economies.\nNotwithstanding any inconsistent provisions of law, rates of payment by\ngovernmental agencies for outpatient services provided by a general\nhospital or diagnostic and treatment center, shall not require a\ncertification by the commissioner that they are reasonable and adequate\nto meet the costs which must be incurred by efficiently and economically\noperated facilities.\n 2-a. Notwithstanding any provision of which is inconsistent with or\ncontrary to the structure established by this subdivision and\nsubdivision thirty-three of section twenty-eight hundred seven-c of this\narticle, and subject to the availability of federal financial\nparticipation, rates of payment by governmental agencies, established\npursuant to this article, for general hospital outpatient services,\ngeneral hospital emergency services, ambulatory surgical services\nprovided by a hospital as defined by subdivision one of section\ntwenty-eight hundred one of this article, and diagnostic and treatment\ncenter services, but excepting any facility whose reimbursement is\ngoverned by subdivision eight of this section or any payments made on\nbehalf of persons enrolled in Medicaid managed care or in the family\nhealth plus program, shall be in accordance with the following:\n (a)(i) for the period December first, two thousand eight through\nNovember thirtieth, two thousand nine, seventy-five percent of such\nrates of payment for each general hospital's outpatient services shall\nreflect the average Medicaid payment per claim, as determined by the\ncommissioner, for services provided by that facility in the two thousand\nseven calendar year, but excluding any payments for services covered by\nthe facility's licensure, if any, under the mental hygiene law, and\ntwenty-five percent of such rates of payment shall, for the operating\ncost component, reflect the utilization of the ambulatory patient groups\nreimbursement methodology described in paragraph (e) of this\nsubdivision;\n (ii) for the period December first, two thousand nine through December\nthirty-first, two thousand ten, fifty percent of such rates for each\nfacility shall reflect the average Medicaid payment per claim, as\ndetermined by the commissioner, for services provided by that facility\nin the two thousand seven calendar year, but excluding any payments for\nservices covered by the facility's licensure, if any, under the mental\nhygiene law, and fifty percent of such rates of payment shall, for the\noperating cost component, reflect the utilization of the ambulatory\npatient groups reimbursement methodology described in paragraph (e) of\nthis subdivision;\n (iii) for the period January first, two thousand eleven through\nDecember thirty-first, two thousand eleven, twenty-five percent of such\nrates shall reflect the average Medicaid payment per claim, as\ndetermined by the commissioner, for services provided by that facility\nfor the two thousand seven calendar year, but excluding any payments for\nservices covered by the facility's licensure, if any, under the mental\nhygiene law, and seventy-five percent of such rates of payment shall,\nfor the operating cost component, reflect the utilization of the\nambulatory patient groups reimbursement methodology described in\nparagraph (e) of this subdivision; and\n (iv) for periods on and after January first, two thousand twelve, one\nhundred percent of such rates of payment shall reflect the utilization\nof the ambulatory patient groups reimbursement methodology described in\nparagraph (e) of this subdivision.\n (v) This paragraph shall be effective the later of: (i) December\nfirst, two thousand eight, or (ii) after the commissioner receives final\napproval of federal financial participation in payments made for\nbeneficiaries eligible for medical assistance under title XIX of the\nfederal social security act for the rate methodology established\npursuant to subparagraph (i) of paragraph (a) of subdivision\nthirty-three of section twenty-eight hundred seven-c of this article.\n (b) (i) for the period September first, two thousand nine through\nNovember thirtieth, two thousand nine, seventy-five percent of such\nrates of payment for services provided by each diagnostic and treatment\ncenter and each free-standing ambulatory surgery center shall reflect\nthe average Medicaid payment per claim, as determined by the\ncommissioner, for services provided by that facility in the two thousand\nseven calendar year, but excluding any payments for services covered by\nthe facility's licensure, if any, under the mental hygiene law, and\ntwenty-five percent of such rates of payment shall, for the operating\ncost component, reflect the utilization of the ambulatory patient groups\nreimbursement methodology described in paragraph (e) of this\nsubdivision;\n (ii) for the period December first, two thousand nine through December\nthirty-first, two thousand ten, fifty percent of such rates for each\nfacility shall reflect the average Medicaid payment per claim, as\ndetermined by the commissioner, for services provided by that facility\nin the two thousand seven calendar year, but excluding any payments for\nservices covered by the facility's licensure, if any, under the mental\nhygiene law, and fifty percent of such rates of payment shall, for the\noperating cost component, reflect the utilization of the ambulatory\npatient groups reimbursement methodology described in paragraph (e) of\nthis subdivision;\n (iii) for the period January first, two thousand eleven through\nDecember thirty-first, two thousand eleven, twenty-five percent of such\nrates for each facility shall reflect the average Medicaid payment per\nclaim, as determined by the commissioner, for services provided by that\nfacility in the two thousand seven calendar year, but excluding any\npayments for services covered by the facility's licensure, if any, under\nthe mental hygiene law, and seventy-five percent of such rates of\npayment shall, for the operating cost component, reflect the utilization\nof the ambulatory patient groups reimbursement methodology described in\nparagraph (e) of this subdivision; and\n (iv) for periods on and after January first, two thousand twelve, one\nhundred percent of such rates of payment shall reflect the utilization\nof the ambulatory patient groups reimbursement methodology described in\nparagraph (e) of this subdivision.\n (c) for periods on and after December first, two thousand eight, such\nrates of payment for ambulatory surgical services provided by general\nhospitals shall reflect the utilization of the ambulatory patient groups\nreimbursement methodology described in paragraph (e) of this\nsubdivision, provided however, that the capital cost component for such\nrates shall be separately computed in accordance with regulations\npromulgated in accordance with paragraph (e) of this subdivision.\n (d) for periods on and after January first, two thousand nine, the\noperating cost component of such rates of payment for general hospital\nemergency services shall reflect the utilization of the ambulatory\npatient groups reimbursement methodology described in paragraph (e) of\nthis subdivision and shall not reflect any maximum payment amount as\notherwise provided for in subparagraph (ii) of paragraph (g) of\nsubdivision two of this section.\n (e) (i) notwithstanding any inconsistent provisions of this\nsubdivision, the commissioner shall promulgate regulations establishing,\nsubject to the approval of the state director of the budget,\nmethodologies for determining rates of payment for the services\ndescribed in this subdivision. Such regulations shall reflect\nutilization of the ambulatory patient group (APG) methodology, in which\npatients are grouped based on their diagnosis, the intensity of the\nservices provided and the medical procedures performed, and with each\nAPG assigned a weight reflecting the projected utilization of resources.\nSuch regulations shall provide for the development of one or more base\nrates and the multiplication of such base rates by the assigned weight\nfor each APG to establish the appropriate payment level for each such\nAPG. Such regulations may also utilize bundling, packaging and\ndiscounting mechanisms.\n If the commissioner determines that the use of the APG methodology is\nnot, or is not yet, appropriate or practical for specified services, the\ncommissioner may utilize existing payment methodologies for such\nservices or may promulgate regulations, and may promulgate emergency\nregulations, establishing alternative payment methodologies for such\nservices.\n (ii) Notwithstanding this subdivision and any other contrary provision\nof law, the commissioner may incorporate within the payment methodology\ndescribed in subparagraph (i) of this paragraph payment for services\nprovided by facilities pursuant to licensure under the mental hygiene\nlaw, provided, however, that such APG payment methodology may be phased\ninto effect in accordance with a schedule or schedules as jointly\ndetermined by the commissioner, the commissioner of mental health, the\ncommissioner of alcoholism and substance abuse services, and the\ncommissioner of the office for people with developmental disabilities.\n (iii) Regulations issued pursuant to this paragraph may incorporate\nquality related measures limiting or excluding reimbursement related to\npotentially preventable conditions and complications; provided however,\nsuch quality related measures shall not include any preventable\nconditions and complications not identified for Medicare nonpayment or\nlimited payment.\n * (iv) Effective April first, two thousand twenty, regulations issued\npursuant to this paragraph for public general hospitals or public health\nsystems, other than those operated by the state of New York or the state\nuniversity of New York, located in a city having a population of one\nmillion or more shall reflect additional reimbursement for costs, to the\nextent permitted under 42 CFR 447.321(b)(1) and based on actual\nutilization of services. Such rate add-on shall be contingent upon\nfederal financial participation and approval, and subject to the terms\nof a binding memorandum of understanding executed between the department\nof health and the public general hospital or public health system\nreceiving the rate add-on. If payment of such rate add-on is projected\nto cause Medicaid disbursements for such period to exceed the projected\ndepartment of health Medicaid state funds in the enacted budget\nfinancial plan pursuant to subdivision three of section twenty-three of\nthe state finance law, as determined by the director of the budget, or\nthe memorandum of understanding is not executed or is breached, the\ncommissioner, in consultation with the director of the budget, may\neither cancel or reduce payment of such rate add-on to achieve\ncompliance with the enacted budget financial plan.\n * NB Repealed March 31, 2026\n (f)(i) The commissioner shall periodically measure the utilization and\nintensity of services provided to medical assistance recipients in\nambulatory settings. Such analysis shall include, but not be limited to:\nmeasurement of the shift of surgical procedures from the inpatient\nhospital setting to the ambulatory setting including measurement of the\nimpact of any such shift on quality of care and outcomes; changes in the\nutilization and intensity of services provided in the outpatient\nhospital department and in diagnostic and treatment centers; and the\nchange in the utilization and intensity of services provided in the\nemergency department.\n (ii) notwithstanding the provisions of paragraphs (a) and (b) of this\nsubdivision, for periods on and after January first, two thousand nine,\nthe following services provided by general hospital outpatient\ndepartments and diagnostic and treatment centers shall be reimbursed\nwith rates of payment based entirely upon the ambulatory patient group\nmethodology as described in paragraph (e) of this subdivision, provided,\nhowever, that the commissioner may utilize existing payment\nmethodologies or may promulgate regulations establishing alternative\npayment methodologies for one or more of the services specified in this\nsubparagraph, effective for periods on and after March first, two\nthousand nine:\n (A) services provided in accordance with the provisions of paragraphs\n(q), (r), and (ll) of subdivision two of section three hundred\nsixty-five-a of the social services law; and\n (B) all services, but only with regard to additional payment amounts,\nas determined in accordance with regulations issued in accordance with\nparagraph (e) of this subdivision, for the provision of such services\nduring times outside the facility's normal hours of operation, as\ndetermined in accordance with criteria set forth in such regulations;\nand\n (C) services provided by licensed social workers, licensed mental\nhealth counselors, and licensed marriage and family therapists, in\naccordance with licensing criteria set forth in applicable regulations;\nand\n (D) individual psychotherapy services provided by licensed social\nworkers, in accordance with licensing criteria set forth in applicable\nregulations, at diagnostic and treatment centers that provided, billed\nfor, and received payment for these services between January first, two\nthousand seven and December thirty-first, two thousand seven;\n (E) services provided to pregnant women pursuant to paragraph (s) of\nsubdivision two of section three hundred sixty-five-a of the social\nservices law and, for periods on and after January first, two thousand\nten, all other services provided pursuant to such paragraph (s) and\nservices provided pursuant to paragraph (t) of subdivision two of\nsection three hundred sixty-five-a of the social services law;\n (F) wheelchair evaluation services and eyeglass dispensing services;\nand\n (G) immunization services, effective for services rendered on and\nafter June tenth, two thousand nine.\n (f-1) Notwithstanding any inconsistent provision of this section or\nany other contrary provision of law, the commissioner may with the\napproval of the director of the budget, for periods prior to two\nthousand twelve, establish rates of payments for selected patient\nservice categories that are based entirely upon the ambulatory patient\ngroups methodology as authorized pursuant to paragraph (e) of this\nsubdivision.\n (g) for the purposes set forth in paragraphs (a) and (b) of this\nsubdivision, rates described as in effect for the two thousand seven\ncalendar year shall mean those rates which are in effect for that year\non the date this subdivision becomes effective and such rates shall not\nthereafter, for the purposes set forth in such paragraphs (a) and (b),\nbe subject to further adjustment.\n (h)(i) To the degree that rates of payment computed in accordance with\nparagraphs (a) and (d) of this subdivision reflect utilization of the\nambulatory patient groups reimbursement methodology described in\nparagraph (e) of this subdivision for purposes of computing the\noperating component of such rates, the computation of the capital cost\ncomponent of such rates shall remain subject to the provisions of\nsubparagraphs (i) and (ii) of paragraph (g) of subdivision two of this\nsection, provided, however, that this subparagraph shall not be\nunderstood as applying to those portions of rates of payment computed\npursuant to paragraph (a) of this subdivision which are based on average\nMedicaid payments per claim.\n (ii) To the degree that rates of payment computed in accordance with\nparagraph (b) of this subdivision reflect utilization of the ambulatory\npatient groups reimbursement methodology described in paragraph (e) of\nthis subdivision for purposes of computing the operating component of\nsuch rates, the computation of the capital cost component of such rates\nshall, for diagnostic and treatment centers, remain subject to the\nprovisions of paragraph (b) of subdivision two of this section and\nshall, for free-standing ambulatory surgery centers, be separately\ncomputed in accordance with regulations promulgated in accordance with\nparagraph (e) of this subdivision, provided, however, that this\nsubparagraph shall not be understood as applying to those portions of\nrates of payment which are based on average Medicaid payments per claim.\n (i) Notwithstanding any provision of law to the contrary, rates of\npayment by governmental agencies for general hospital outpatient\nservices, general hospital emergency services and ambulatory surgical\nservices provided by a general hospital established pursuant to\nparagraphs (a), (c) and (d) of this subdivision shall result in an\naggregate increase in such rates of payment of fifty-six million dollars\nfor the period December first, two thousand eight through March\nthirty-first, two thousand nine and one hundred seventy-eight million\ndollars for periods after April first, two thousand nine, through March\nthirty-first, two thousand thirteen, and one hundred fifty-three million\ndollars for state fiscal year periods on and after April first, two\nthousand thirteen, provided, however, that for periods on and after\nApril first, two thousand nine, such amounts may be adjusted to reflect\nprojected decreases in fee-for-service Medicaid utilization and changes\nin case-mix with regard to such services from the two thousand seven\ncalendar year to the applicable rate year, and provided further,\nhowever, that funds made available as a result of any such decreases may\nbe utilized by the commissioner to increase capitation rates paid to\nMedicaid managed care plans and family health plus plans to cover\nincreased payments to health care providers for ambulatory care services\nand to increase such other ambulatory care payment rates as the\ncommissioner determines necessary to facilitate access to quality\nambulatory care services.\n 3. Commissioner rate certification, governmental payments. Prior to\nthe approval of such rates, as provided in subdivision two of this\nsection, the commissioner shall determine, and in the case of approvals\nby the state director of the budget, certify to such official that the\nproposed rate schedules for payments to hospitals for hospital and\nhealth-related services are reasonable and adequate to meet the costs\nwhich must be incurred by efficiently and economically operated\nfacilities. In making such certification, the commissioner shall take\ninto consideration the elements of cost, geographical differentials in\nthe elements of cost considered, economic factors in the area in which\nthe hospital is located, the rate of increase or decrease of the economy\nin the area in which the hospital is located, costs of hospitals of\ncomparable size, and the need for incentives to improve services and\ninstitute economies. The commissioner shall also take into\nconsideration the economies and improvements in service to be\nanticipated from the operation of joint central service or use of\nfacilities or services which may serve as alternatives or substitutes\nfor the whole or any part of in-hospital service, including, but not\nlimited to, obstetrical, pediatric, laboratory, training, radiology,\npharmacy, laundry, purchasing, preadmission, nursing home, ambulatory or\nhome care services. The commissioner shall exclude costs for research\nand those parts of the costs for educational salaries which the\ncommissioner shall determine to be not directly related to hospital\nservice, and allowances for costs which are not specifically identified\nexcept for allowances authorized under section twenty-eight hundred\nseven-a or twenty-eight hundred seven-c of this article. In determining\nand certifying to the state director of the budget rates of payment,\nincluding rates of payment for residential health care facilities, the\ncommissioner shall take into consideration the different levels of care\nauthorized to be provided in such hospital or health-related service and\ndetermine and certify distinct rates of payment for each such level of\ncare. If the modification of an operating certificate of a hospital\npursuant to subdivision six of section twenty-eight hundred six of this\narticle requires the establishment of a rate for a level of service not\npreviously provided in such hospital during the rate period existing at\nthe time of such modification, a new rate period for that portion of the\nhospital reclassified as a result of such modification may be\nestablished upon sixty days' prior notice.\n 4. Commissioner rate certifications, payments pursuant to the\nprovisions of the workers' compensation law, the volunteer firefighters'\nbenefit law, the volunteer ambulance workers' benefit law and the\ncomprehensive motor vehicle insurance reparations act. For the rate\nyears commencing January first, nineteen hundred eighty-six and January\nfirst, nineteen hundred eighty-seven the commissioner shall submit to\nthe chairman of the workers' compensation board a schedule of hospital\ninpatient reimbursement rates computed in accordance with subdivision\ntwo of section twenty-eight hundred seven-a of this article or as\nrevised pursuant to subdivisions eleven and fourteen of section\ntwenty-eight hundred seven-a of this article. Beginning with the rate\nperiod commencing January first, nineteen hundred eighty-eight the\ncommissioner shall submit, and beginning with the rate period January\nfirst, nineteen hundred ninety-seven and certify, to the chairman of the\nworkers' compensation board for an established rate period a schedule of\nhospital inpatient reimbursement rates computed in accordance with\nsubdivision one of section twenty-eight hundred seven-c of this article\nfor payments pursuant to the workers' compensation law, the volunteer\nfirefighters' benefit law and the comprehensive motor vehicle insurance\nreparations act and beginning with the rate year commencing January\nfirst, nineteen hundred ninety-one including payments pursuant to the\nvolunteer ambulance workers' benefit law.\n 5. Audit authority. The commissioner shall make available to the\ncommissioner of social services, in a mutually satisfactory manner, all\ninformation necessary to conduct or have conducted, on a cost sharing\nbasis among payors, an appropriate review or audit of the fiscal and\nstatistical records of a hospital necessary to implement the provisions\nof this article.\n 6. Consideration of economic status in certain cases. Notwithstanding\nthe provisions of this section, the commissioner, in determining and\ncertifying rates of payment for services provided by a party to a\ncontract entered into pursuant to the provisions of subdivision three of\nsection twenty-eight hundred three of this article, shall take into\nconsideration the economic status of the patients receiving such\nservices.\n 7. Reimbursement rate promulgation. The commissioner shall notify each\nresidential health care facility and health-related service of its\napproved rates of payment which shall be used in reimbursing for\nservices provided to persons eligible for payments made by state\ngovernmental agencies at least sixty days prior to the beginning of an\nestablished rate period for which the rate is to become effective and\nfor general hospitals at least thirty days prior to the beginning of an\nestablished rate period for which the rate is to become effective.\nNotification shall be made only after approval of rate schedules by the\nstate director of the budget. The sixty and thirty day notice\nprovisions, herein, shall not apply to rates issued following judicial\nannulment or invalidation of any previously issued rates, or rates\nissued pursuant to changes in the methodology used to compute rates\nwhich changes are promulgated following the judicial annulment or\ninvalidation of previously issued rates. Notwithstanding any provision\nof law to the contrary, nothing in this subdivision shall prohibit the\nrecalculation and payment of rates, including both positive and negative\nadjustments, based on a reconciliation of amounts paid by residential\nhealth care facilities beginning April first, nineteen hundred\nninety-seven for additional assessments or further additional\nassessments pursuant to section twenty-eight hundred seven-d of this\narticle with the amounts originally recognized for reimbursement\npurposes.\n 7-a. Notwithstanding any inconsistent provision of law, with regard to\na general hospital the provisions of subdivisions four and seven of this\nsection and the provisions of section eighteen of chapter two of the\nlaws of nineteen hundred eighty-eight relating to the requirement of\nprior notice and the time frames for notice, approval or certification\nof rates of payment, maximum rates of payment or maximum charges where\nnot otherwise waived pursuant to law shall be applicable only to such\nrates of payment or maximum charges prospectively established for an\nannual rate period and such provisions shall not be applicable to a\ngeneral hospital with regard to prospective adjustments or retrospective\nadjustments of established rates of payment or maximum charges for or\nduring an annual rate period based on correction of errors or omissions\nof data or in computation, rate appeals, audits or other rate\nadjustments authorized by law or regulations adopted pursuant to section\ntwenty-eight hundred three of this article.\n 7-b. Notification of diagnostic and treatment center approved rates.\n(a) For rate periods or portions of rate periods beginning on or after\nOctober first, nineteen hundred ninety-four, the commissioner shall\nnotify each diagnostic and treatment center of its approved rates of\npayment, which shall be used in the reimbursement for services provided\nto persons eligible for payments made by state governmental agencies at\nleast thirty days prior to the beginning of the period for which such\nrates are to become effective.\n (b) Notwithstanding any contrary provision of law, all diagnostic and\ntreatment centers certified on or before September second, nineteen\nhundred ninety-seven shall, not later than September second, nineteen\nhundred ninety-seven, notify the commissioner whether they intend to\nmaintain all books and records utilized by the diagnostic and treatment\ncenter for cost reporting and reimbursement purposes on a calendar year\nbasis or, commencing on July first, nineteen hundred ninety-six, on a\nJuly first through June thirtieth basis, and shall thereafter maintain\nall books and records on such basis. All diagnostic and treatment\ncenters certified after September second, nineteen hundred ninety-seven\nshall notify the commissioner at the time of certification whether they\nintend to maintain all books and records on a calendar year basis or on\nor a July first through June thirtieth basis, and shall thereafter\nmaintain all books and records on such a basis.\n (c) The books and records maintained pursuant to paragraph (b) of this\nsubdivision shall be utilized and made available to the commissioner in\npromulgating rates of payment for annual rate periods beginning on or\nafter October first, nineteen hundred ninety-seven.\n (d) Notwithstanding any provision of the law to the contrary, rates of\npayment established in accordance with paragraph (b) as amended, and\nparagraph (f) of subdivision two of this section for the rate period\nbeginning April first, nineteen hundred ninety-three shall continue in\neffect through September thirtieth, nineteen hundred ninety-four, and\napplicable trend factors shall be applied to that portion of such rates\nof payment for the rate period which begins April first, nineteen\nhundred ninety-four.\n 8. Rates for federally qualified health centers and rural health\ncenters. Notwithstanding section four of chapter eighty-one of the laws\nof nineteen hundred ninety-five, as amended by section twenty-seven of\nchapter one of the laws of nineteen hundred ninety-nine, and any other\nlaw, rule or regulation to the contrary, for periods on and after\nJanuary first, two thousand one, rates of payment made by governmental\nagencies for services provided by diagnostic and treatment centers or\ngeneral hospital outpatient clinics licensed under this article to\nindividuals eligible for medical assistance pursuant to title eleven of\narticle five of the social services law which are also designated, in\naccordance with 42 USC § 1396a(aa), as federally qualified health\ncenters or rural health centers shall be established in accordance with\nthe following:\n (a) For periods on and after January first, two thousand one, and\nprior to October first, two thousand one, such rates of payment shall be\ncomputed in accordance with paragraph (b) of subdivision two of this\nsection, provided, however, that the operating and capital cost\ncomponents of such rates and the applicable ceilings on allowable\noperating costs shall reflect an average of nineteen hundred ninety-nine\nand two thousand base year costs as reported to the department.\n (b) For each twelve month period following September thirtieth, two\nthousand one, the operating cost component of such rates of payment\nshall reflect the operating cost component in effect on September\nthirtieth of the prior period as increased by the percentage increase in\nthe Medicare Economic Index as computed in accordance with the\nrequirements of 42 USC § 1396a(aa)(3) and as adjusted pursuant to\napplicable regulations to take into account any increase or decrease in\nthe scope of services furnished by the facility.\n (c) Rates of payments to facilities which first qualify as federally\nqualified health centers or rural health centers on or after October\nfirst, two thousand shall be computed in accordance with the provisions\nof paragraph (b) of subdivision two of this section, provided, however,\nthat the operating cost component of such rates shall reflect an average\nof the operating cost component of rates of payments issued to other\nfacilities subject to this subdivision during the same rate period,\nlocated in the same geographic region and with a similar case load, and\nfurther provided that the capital cost component of such rates shall\nreflect the most recently available capital cost data as reported to the\ndepartment. For each twelve month period following the rate period in\nwhich such facilities commence operation, the operating cost component\nof rates of payment for such facilities shall be computed in accordance\nwith paragraph (b) of this subdivision. In calculating the operating\ncost component of such rates for facilities which first qualify as\nfederally qualified health care centers on or after October first, two\nthousand, the counties comprising the geographic region known as\ndownstate shall be the same as the counties comprising the downstate\nregion for purposes of reimbursing diagnostic and treatment centers\nunder ambulatory patient groups, which counties are specified in the\nregulations adopted by the commissioner implementing section 18 of part\nC of chapter fifty-eight of the laws of two thousand eight.\n (d) Subject to receipt of all necessary federal approvals, rates of\npayment computed in accordance with this subdivision may be further\nadjusted in accordance with the provisions of subdivision seventeen of\nthis section, provided, however, that such adjustments shall not be\nsubject to trend adjustments as provided in paragraph (b) of this\nsubdivision.\n (e) Diagnostic and treatment centers eligible for rates of payment\ncomputed pursuant to paragraphs (a) and (b) of this subdivision, which\nwere, on December thirty-first, two thousand, receiving rates of payment\nas preferred primary care providers computed pursuant to paragraph (h)\nof subdivision two of this section, may elect to continue to receive\nrates of payment computed in accordance with such paragraph (h),\nprovided that in no event shall such rates of payment be less than the\nrates of payment computed pursuant to paragraphs (a) and (b) of this\nsubdivision.\n (f) For any rate periods after March thirty-first, two thousand eight,\nsubject to the availability of federal financial participation, the\ncommissioner may prospectively adjust rates of payment for facilities\notherwise subject to this subdivision to reflect alternative\nrate-setting methodologies, provided, however, that such alternative\nrate-setting methodologies must: (i) be authorized by applicable state\nlaw, (ii) be agreed to by the commissioner and each facility to which\nthey are applied and (iii) in no event result in rates that are, in\naggregate, less than the rates of payment otherwise provided for in this\nsubdivision.\n 9. Payments under this section not to preclude other lawful payments.\nAny payments made under the authority of this section or section\ntwenty-eight hundred seven-c of this article shall not preclude payments\nunder any other section of law.\n 10. Notwithstanding the provisions of this article, the commissioner\nmay waive, subject to the approval of the state director of the budget,\nthe requirements of any provisions of this section, section twenty-eight\nhundred seven-a or twenty-eight hundred seven-c of this article to\npermit the development and/or continuation of limited pilot\nreimbursement programs to provide additional knowledge and experience in\ndifferent types of reimbursement mechanisms for general hospitals.\n * 11. Notwithstanding the provisions of this article, the commissioner\nmay waive, subject to the approval of the state director of the budget,\nthe requirements of any provision of this section, section twenty-eight\nhundred seven-a or twenty-eight hundred seven-c of this article to\npermit the development, implementation and operation of limited pilot\nreimbursement programs for general hospital outpatient services and\ndiagnostic and treatment center services that would be prospective and\nassociated to the resource use patterns in rendering ambulatory care\nservices.\n * NB Expired April 1, 2020\n 12. (a) Notwithstanding any inconsistent provision of this article or\nany other law, for the purpose of improving access to and availability\nof comprehensive primary health care to persons receiving medical\nassistance pursuant to title eleven of article five of the social\nservices law, the commissioner, upon application by a health care\nprovider, may designate such provider as a preferred primary care\nprovider in accordance with the provisions of this subdivision.\n (b) Health care providers designated as preferred primary care\nproviders pursuant to this subdivision shall meet such requirements as\nmay be established by the commissioner in regulation, including, but not\nlimited to:\n (i) access by the medically indigent and medicaid eligible to\nambulatory services;\n (ii) provision, to the maximum extent practicable, of continuity of\ncare;\n (iii) arrangements for specialty physician care and necessary\nancillary services;\n (iv) reasonably accessible hours of operation;\n (v) services which are accessible to medically underserved populations\nand communities including, to the maximum extent feasible, offering such\nservices within the medically underserved community; and\n (vi) participation in local social services district managed care\nprograms established pursuant to section three hundred sixty-four-j of\nthe social services law, provided that the commissioner, in consultation\nwith the commissioner of social services, may exempt a health care\nprovider from such participation for good cause. Good cause shall\ninclude but not be limited to geographic inaccessibility to managed care\nprograms, inability to coordinate services of managed care programs, or\nthat participation in the managed care program would significantly\naffect the provider's financial ability to provide services.\n (c) For the purposes of this subdivision, a health care provider\neligible to be designated as a preferred primary care provider shall\nmean a general hospital, a diagnostic and treatment center, a private\nphysician, a nurse practitioner, a midwife, a professional corporation\nor a group of physicians or nurse practitioners. The designation of any\ngeneral hospital or a diagnostic and treatment center as a preferred\nprimary care provider shall apply only to the specific site where the\nentity provides comprehensive primary health care services.\n * 13. Subject to the availability of funds, the commissioner shall\nauthorize health occupation development and workplace demonstration\nprograms pursuant to the provisions of section two thousand eight\nhundred seven-h of this article for diagnostic and treatment centers,\nand the commissioner is hereby directed to make rate adjustments to\ncover the cost of such programs.\n * NB Expired July 1, 2017\n * 14. Notwithstanding any inconsistent provision of law or regulation,\nfor purposes of establishing rates of payment by governmental agencies\nfor diagnostic and treatment centers for services provided on or after\nApril first, nineteen hundred ninety-five, the reimbursable base year\nadministrative and general costs of a provider, excluding a provider\nreimbursed on an initial budget basis, shall not exceed the statewide\naverage of total reimbursable base year administrative and general costs\nof diagnostic and treatment centers. For the purposes of this\nsubdivision, reimbursable base year administrative and general costs\nshall mean those base year administrative and general costs remaining\nafter application of all other efficiency standards, including, but not\nlimited to, peer group cost ceilings or guidelines. The limitation on\nreimbursement for provider administrative and general expenses provided\nby this subdivision shall be expressed as a percentage reduction of the\noperating cost component of the rate promulgated by the commissioner for\neach diagnostic and treatment center with base year administrative and\ngeneral costs exceeding the average.\n * NB Expired March 31, 2011\n 15. Notwithstanding any inconsistent provision of law, including\nsubdivision fourteen of this section, the facility-specific impact of\neliminating the statewide cap on administrative and general costs, as\nimposed pursuant to subdivision fourteen of this section, for the period\nApril first, nineteen hundred ninety-nine through June thirtieth,\nnineteen hundred ninety-nine pursuant to a chapter of the laws of\nnineteen hundred ninety-nine, shall be included in rates of payment for\nfacilities affected by such elimination for the period October first,\nnineteen hundred ninety-nine through December thirty-first, nineteen\nhundred ninety-nine. In addition, rates for diagnostic and treatment\ncenters for the period October first, nineteen hundred ninety-nine\nthrough December thirty-first, nineteen hundred ninety-nine shall\ninclude, in the aggregate, the sum of fourteen million dollars which\nshall be added to rates of payment established in accordance with\nparagraphs (b) and (h) of subdivision two of this section based on an\napportionment of such amount using a ratio of each individual provider's\nestimated medicaid expenditures to total estimated medicaid expenditures\nfor diagnostic and treatment centers, as determined by the commissioner,\nfor the October first, nineteen hundred ninety-nine through September\nthirtieth, two thousand rate period.\n 16. Notwithstanding any inconsistent provision of law, payment for\ndrugs which may not be dispensed without a prescription as required by\nsection sixty-eight hundred ten of the education law provided to persons\nreceiving medical assistance pursuant to title eleven of article five of\nthe social services law by any non-hospital based diagnostic and\ntreatment center licensed under this article in existence on the\neffective date of this subdivision providing comprehensive primary\nmedical care services and registered by the state board of pharmacy\npursuant to section sixty-eight hundred eight of the education law shall\nbe on a fee-for-service basis and shall not be included in any\ncomprehensive clinic rate paid to such facility by governmental agencies\nestablished in accordance with paragraph (b) of subdivision two of this\nsection.\n 17. (a) Notwithstanding any contrary provision of law or regulation,\nthe commissioner shall, subject to the availability of federal financial\nparticipation, adjust medical assistance rates of payment established\npursuant to paragraph (b) of subdivision two of this section for\nfree-standing diagnostic and treatment centers licensed pursuant to this\narticle and which are: a "covered provider" as defined in subdivision\none of section three hundred sixty-four-j-two of the social services\nlaw; or eligible for an allocation under paragraph (a-1) of subdivision\ntwo of section three hundred sixty-four-j-two of the social services\nlaw; or which provides services to individuals with developmental\ndisabilities as their principal mission, in accordance with paragraphs\n(b) and (c) of this subdivision for purposes of improving recruitment\nand retention of non-supervisory workers at health care facilities or\nany worker with direct patient care responsibility in the following\naggregate amounts for the following periods:\n (i) for the period April first, two thousand two through December\nthirty-first, two thousand two, thirteen million dollars;\n (ii) for the period January first, two thousand three through December\nthirty-first, two thousand three, thirteen million dollars;\n (iii) for the period January first, two thousand four through December\nthirty-first, two thousand four, thirteen million dollars;\n (iv) for the period January first, two thousand five through December\nthirty-first, two thousand five, thirteen million dollars;\n (v) for the period January first, two thousand six through December\nthirty-first, two thousand six, thirteen million dollars;\n (vi) for the period January first, two thousand seven through June\nthirtieth, two thousand seven, six million five hundred thousand\ndollars;\n (vii) for the period July first, two thousand seven through March\nthirty-first, two thousand eight, nine million seven hundred fifty\nthousand dollars; and\n (viii) thirteen million dollars for the period April first, two\nthousand eight through March thirty-first, two thousand nine;\n (ix) thirteen million dollars for the period April first, two thousand\nnine through March thirty-first, two thousand ten; and\n (x) thirteen million dollars for the period April first, two thousand\nten through March thirty-first, two thousand eleven.\n (b) Such adjustments to rates of payments shall be allocated\nproportionally based on each diagnostic and treatment center's total\nannual gross salary and fringe benefit costs, as reported in each such\ndiagnostic and treatment center's nineteen hundred ninety-nine cost\nreport as submitted to the department prior to November first, two\nthousand one, provided, however, that for periods on and after July\nfirst, two thousand seven, such adjustments to rates of payment shall be\nallocated proportionally, based on each such diagnostic and treatment\ncenter's total reported medicaid visits, as reported in each such\ndiagnostic and treatment center's two thousand four cost report as\nsubmitted to the department prior to January thirty-first, two thousand\nseven, to the total of such medicaid visits for all diagnostic and\ntreatment centers.\n (c) Rate adjustments made pursuant to this subdivision shall not be\nsubject to subsequent adjustment or reconciliation.\n (d) Diagnostic and treatment centers which have their rates adjusted\npursuant to this subdivision shall use such funds for the purpose of\nrecruitment and retention of non-supervisory workers at health care\nfacilities or any worker with direct patient care responsibility and are\nprohibited from using such funds for any other purpose. Each such\ndiagnostic and treatment center shall submit, at a time and in a manner\nto be determined by the commissioner, a written certification attesting\nthat such funds will be used solely for the purpose of recruitment and\nretention of non-supervisory workers at health care facilities or any\nworker with direct patient care responsibility. The commissioner is\nauthorized to audit each such diagnostic and treatment center to ensure\ncompliance with the written certification required by this paragraph and\nshall recoup any funds determined to have been used for purposes other\nthan recruitment and retention of non-supervisory workers at health care\nfacilities or any worker with direct patient care responsibility. Such\nrecoupment shall be in addition to any other penalties provided by law.\n 18. (a) Notwithstanding any contrary provision of law or regulation,\nthe commissioner shall, subject to the provisions of paragraph (c) of\nthis subdivision and to the availability of federal financial\nparticipation, increase medical assistance rates of payment established\npursuant to paragraph (b) of subdivision two of this section for\neligible diagnostic and treatment centers by three percent for services\nprovided on and after December first, two thousand two for purposes of\nimproving recruitment and retention of non-supervisory workers or any\nworker with direct patient care responsibility.\n (b) For the purposes of this subdivision, "eligible diagnostic and\ntreatment center" shall mean a voluntary, not-for-profit diagnostic and\ntreatment center licensed under this article that received medical\nassistance rates of payment reflecting assignment to limited primary\ncare or drug free peer groups as established pursuant to applicable\nrate-setting regulations and that provides primary health care services\nto a patient population primarily comprised of substance abuse patients\nand that is ineligible for an adjustment to medical assistance rates of\npayment under subdivision seventeen of this section.\n (c) Diagnostic and treatment centers which have their rates adjusted\npursuant to this subdivision shall use such funds solely for the purpose\nof recruitment and retention of non-supervisory workers or any worker\nwith direct patient care responsibility and are prohibited from using\nsuch funds for any other purpose. Each such diagnostic and treatment\ncenter shall submit, at a time and in a manner to be determined by the\ncommissioner, a written certification attesting that such funds will be\nused solely for the purpose of recruitment and retention of\nnon-supervisory workers or any worker with direct patient care\nresponsibility. The commissioner is authorized to audit each such\ndiagnostic and treatment center to ensure compliance with the written\ncertification required by this paragraph and shall recoup any funds\ndetermined to have been used for purposes other than recruitment and\nretention of non-supervisory workers or any worker with direct patient\ncare responsibility. Such recoupment shall be in addition to any other\npenalties provided by law.\n 19. (a) Notwithstanding any provision of law, rule or regulation to\nthe contrary and subject to the provisions of paragraph (b) of this\nsubdivision and to the availability of federal financial participation,\nthe commissioner shall increase medical assistance rates of payment by\nthree percent for services provided on and after December first, two\nthousand two by freestanding methadone maintenance service and program\nproviders issued operating certificates pursuant to this article and\nsection 32.09 of the mental hygiene law for the purposes of improving\nrecruitment and retention of methadone maintenance workers.\n (b) Freestanding methadone maintenance services and program providers\nwhich are eligible for rate adjustments pursuant to this subdivision and\nwhich are also eligible for rate adjustments pursuant to subdivision\nseventeen of this section, shall, on or before July first, two thousand\ntwo, submit, in a form and manner determined by the commissioner,\namendments to designated sections of their AHCF-1 cost report\nsegregating wages and fringe benefit costs associated with methadone\nmaintenance services from all other services for the purposes of\ndetermining awards made pursuant to subdivision seventeen of this\nsection for rate periods ending in two thousand three and in two\nthousand four.\n (c) Freestanding methadone maintenance service and program providers\nwhich have their rates adjusted pursuant to this subdivision shall use\nsuch funds solely for the purpose of recruitment and retention of\nnon-supervisory workers or any worker with direct patient care\nresponsibility and are prohibited from using such funds for any other\npurpose. Each such methadone maintenance service and program provider\nshall submit, at a time and in a manner to be determined by the\ncommissioner, a written certification attesting that such funds will be\nused solely for the purpose of recruitment and retention of\nnon-supervisory workers at such programs or any worker with direct\npatient care responsibility. The commissioner is authorized to audit\neach such methadone maintenance service and program provider to ensure\ncompliance with the written certification required by this paragraph and\nshall recoup any funds determined to have been used for purposes other\nthan recruitment and retention of non-supervisory workers or any worker\nwith direct patient care responsibility. Such recoupment shall be in\naddition to any other penalties provided by law.\n 20. (a) Notwithstanding any contrary provision of law and subject to\nthe receipt of all necessary federal approvals and the availability of\nfederal financial participation, the commissioner is authorized to enter\ninto agreements with SUNY downstate medical center, other public general\nhospitals, and/or with the sponsoring local governments of such other\npublic general hospitals, under which such facilities and/or such local\ngovernment shall, by intergovernmental transfer, fund the non-federal\nshare of Medicaid funds made available for Delivery System Reform\nIncentive Payments ("DSRIP") to such facilities. Such non-federal share\npayments shall be deemed voluntary and, further, such payments shall be\nexcluded from computations made pursuant to section one of part C of\nchapter fifty-eight of the laws of two thousand five, as amended. In\naddition, the facilities, and/or the sponsoring local governments of\nsuch facilities or the state may, by written notification to the other\nparties to the agreement, cancel such agreement at any time prior to the\npayment of the DSRIP funds. The commissioner shall, to the maximum\ndegree practicable, and to the extent permitted by the federal Centers\nfor Medicare and Medicaid Services ("CMS"), ensure that the DSRIP\nprogram is implemented throughout the entire state.\n (b) The commissioner shall establish an advisory panel to provide\nassistance with regard to the DSRIP program. The panel shall be charged\nwith reviewing recommendations for DSRIP funding made by the state's\ncontracted DSRIP assessor and advising the commissioner regarding the\nresults of such review. Such panel shall also review applications under\nparagraph (b) of subdivision two of section twenty-eight hundred\ntwenty-five of this article. Panel membership shall be comprised of\nindividuals with significant health care system experience. Members may\nnot be elected officials or employed by providers that would benefit\nfrom DSRIP funding, and must not have any conflict of interest that\nwould prevent them from providing an impartial review of DSRIP assessor\nrecommendations. The panel shall consist of members appointed by the\ncommissioner and shall in addition consist of one member appointed by\nthe majority leader of the New York state senate, and one member\nappointed by the speaker of the New York state assembly. The panel shall\ncarry out the review of DSRIP recommendations in strict accordance with\nall requirements set forth in the state's federal 1115 Medicaid waiver\nstandard terms and conditions. The panel shall submit its\nrecommendations to the commissioner for final determination, in\naccordance with all requirements set forth in the state's federal 1115\nMedicaid waiver standard terms and conditions. The commissioner may\nmodify the requirements of this paragraph and paragraph (c) of this\nsubdivision if such modifications are required by the federal CMS.\n (c)(i) Project advisory committees. 1. Lead entities of systems\nestablished under the Medicaid delivery system reform incentive payment\n("DSRIP") program shall establish a project advisory committee. The\ncommittee shall consider and advise the entity on matters concerning\nsystem operations, service delivery issues, elimination of health care\ndisparities, measurement of project outcomes, the degree to which\nproject goals are being reached and the development of any plans or\nprograms. The entity may establish rules with respect to its project\nadvisory committee.\n (ii) The members of the committee shall be representatives of the\ncommunity, or geographic service areas, served by the system, including\nMedicaid consumers attributed to that system, and any other members\nrequired by the terms and conditions of the DSRIP program. The lead\nentity shall file with the commissioner, and from time to time update,\nan up-to-date list of the members of the committee, which shall be made\navailable to the public by the department on its website.\n (iii) Notwithstanding any inconsistent provision of law, no officer or\nemployee of the state or of any civil division thereof, shall be deemed\nto have forfeited or shall forfeit his or her office or employment by\nreason of his or her acceptance of membership on a project advisory\ncommittee. No member of a project advisory committee shall receive\ncompensation or allowance for services rendered on the committee,\nexcept, however, that members of a committee may be reimbursed by the\nentity or system for necessary expenses incurred in relation to service\non a project advisory committee.\n (d) For periods on and after April first, two thousand fourteen, the\ncommissioner shall provide a report on a quarterly basis to the chairs\nof the senate finance, assembly ways and means, senate health and\nassembly health committees with regard to the status of the DSRIP\nprogram. Such reports shall be submitted no later than sixty days after\nthe close of the quarter, and shall include the most current information\nsubmitted by providers to the state and the federal CMS. The reports\nshall include:\n (i) analysis of progress made toward DSRIP goals;\n (ii) the impact on the state's health care delivery system;\n (iii) information on the number and types of providers who\nparticipate;\n (iv) plans and progress for monitoring provider compliance with\nrequirements;\n (v) a status update on project milestone progress;\n (vi) information on project spending and budget;\n (vii) analysis of impact on Medicaid beneficiaries served;\n (viii) a summary of public engagement and public comments received;\n (ix) a description of DSRIP funding applications that were denied;\n (x) a description of all regulation waivers issued pursuant to\nparagraph (f) of this subdivision; and\n (xi) a summary of the statewide geographic distribution of funds.\n (e) For periods on and after April first, two thousand fourteen the\ncommissioner shall promptly make all DSRIP governing documents,\nincluding 1115 waiver standard terms and conditions, supporting\nattachments and detailed project descriptions, and all materials made\navailable to the legislature pursuant to paragraph (d) of this\nsubdivision, available on the department's website. The commissioner\nshall also provide a detailed overview on the department's website of\nthe opportunities for public comment on the DSRIP program.\n (f) Notwithstanding any provision of law to the contrary, the\ncommissioners of the department of health, the office of mental health,\nthe office for people with developmental disabilities, and the office of\nalcoholism and substance abuse services are authorized to waive any\nregulatory requirements as are necessary, consistent with applicable\nlaw, to allow applicants under this subdivision and paragraph (a) of\nsubdivision two of section twenty-eight hundred twenty-five of this\narticle to avoid duplication of requirements and to allow the efficient\nimplementation of the proposed project; provided, however, that\nregulations pertaining to patient safety may not be waived, nor shall\nany regulations be waived if such waiver would risk patient safety. Such\nwaiver shall not exceed the life of the project or such shorter time\nperiods as the authorizing commissioner may determine. Any regulatory\nrelief granted pursuant to this subdivision shall be described,\nincluding each regulation waived and the project it relates to, in the\nreport provided pursuant to paragraph (d) of this subdivision.\n * 20-a. Notwithstanding any provision of law to the contrary, the\ncommissioners of the department of health, the office of mental health,\nthe office of people with developmental disabilities, and the office of\nalcoholism and substance abuse services are authorized to waive any\nregulatory requirements as are necessary, consistent with applicable\nlaw, to allow providers that are involved in DSRIP projects or\nreplication and scaling activities, as approved by the authorizing\ncommissioner, to avoid duplication of requirements and to allow the\nefficient scaling and replication of DSRIP promising practices, as\ndetermined by the authorizing commissioner; provided however, that\nregulations pertaining to patient safety, patient autonomy, patient\nprivacy, patient rights, due process, scope of practice, professional\nlicensure, environmental protections, provider reimbursement\nmethodologies, or occupational standards and employee rights may not be\nwaived, nor shall any regulations be waived if such waiver would risk\npatient safety. Any regulatory action under this subdivision shall be\npublished on the applicable website of the authorizing commissioner and\nshall include a description of each waiver, including a citation of each\nregulation waived, and a description of the project of which such relief\nwas granted.\n * NB Expires April 1, 2026\n 21. (a) Notwithstanding any contrary provision of law and subject to\nthe receipt of all necessary federal approvals and the availability of\nfederal financial participation, the commissioner is authorized to enter\ninto agreements with SUNY downstate medical center, other public general\nhospitals, and/or with the sponsoring local governments of such other\npublic general hospitals, under which such facilities and/or such local\ngovernment shall, by intergovernmental transfer, fund the non-federal\nshare of Medicaid funds made available for implementation of Medicaid\nRedesign Team initiatives. Such non-federal share payments shall be\ndeemed voluntary and, further, such payments shall be excluded from\ncomputations made pursuant to section one of part C of chapter\nfifty-eight of the laws of two thousand five, as amended. In addition,\nthe facilities, and/or the sponsoring local governments of such\nfacilities or the state may, by written notification to the other\nparties to the agreement, cancel such agreement at any time prior to the\npayment of the Medicaid Redesign Team initiatives funds.\n (b) Applications by eligible applicants for Medicaid Redesign Team\ninitiatives funded by monies made available pursuant to paragraph (a) of\nthis subdivision shall be submitted for review to the advisory panel\nestablished pursuant to paragraph (b) of subdivision twenty of this\nsection and such panel shall submit their recommendations to the\ncommissioner for final determination. For periods on and after April\nfirst, two thousand fourteen, the commissioner shall provide a report on\na quarterly basis to the majority leader of the New York state senate\nand to the speaker of the New York state assembly with regard to the\nstatus of such applications and approved projects. Such reports shall be\nsubmitted no later than sixty days after the close of the quarter, and\nshall include the most current information submitted by applicants to\nthe state. The reports shall be submitted in conjunction with and as a\npart of the reports submitted pursuant to paragraph (c) of subdivision\ntwenty of this section and shall include:\n (i) analysis of progress made toward project goals;\n (ii) the impact on the state's health care delivery system;\n (iii) information on the number and types of providers who\nparticipate;\n (iv) plans and progress for monitoring provider compliance with\nrequirements;\n (v) a status update on project milestone progress;\n (vi) information on project spending and budget;\n (vii) analysis of impact on Medicaid beneficiaries served;\n (viii) a summary of public engagement and public comments received;\n (ix) a description of applications that were denied;\n (x) a description of all regulation waivers issued pursuant to\nparagraph (e) of this subdivision; and\n (xi) a summary of the statewide geographic distribution of funds.\n (c) The commissioner shall make all reports prepared pursuant to\nparagraph (b) of this subdivision and all supporting attachments and\nmaterials available on the department's website.\n (d) Notwithstanding any inconsistent law to the contrary, and subject\nto federal financial participation, and subject to amounts appropriated\nfor purposes herein, the department may distribute funds to make rate\nadjustments for health home providers as described in section three\nhundred sixty-five-l of the social services law for member engagement,\nstaff training and retraining, health information technology\nimplementation, joint governance technical assistance, and other such\npurposes as the commissioner, in consultation with the commissioners of\nthe office of mental health and the office of alcoholism and substance\nabuse services determines.\n (e) Notwithstanding any provisions of law to the contrary, the\ncommissioners of the department of health, the office of mental health,\nthe office for people with developmental disabilities, and the office of\nalcoholism and substance abuse services are authorized to waive any\nregulatory requirements as are necessary, consistent with applicable\nlaw, to allow applicants under this subdivision and paragraph (a) of\nsubdivision two of section twenty-eight hundred twenty-five of this\narticle to avoid duplication of requirements and to allow the efficient\nimplementation of the proposed project; provided, however, that\nregulations pertaining to patient safety may not be waived, not shall\nany regulation be waived if such waiver would risk patient safety. Such\nwaiver shall not exceed the life of the project or such shorter time\nperiod as the authorizing commissioner any determine. Any regulatory\nrelief granted pursuant to this subdivision shall be described,\nincluding each regulation waived and the project it relates to, in the\nreport provided pursuant to paragraph (b) of this subdivision.\n