Clinic Treatment Programs
14 NYCRR Part 599
Express Terms
Adoption

A new Part 599 is added to read as follows:

PART 599
CLINIC TREATMENT PROGRAMS
(Statutory Authority:  Mental Hygiene Law §§7.09, 31.02, 31.04, 31.06, 31.07, 31.09, 31.11,
31.13, 31.19, 41.13, 43.01, 43.02 [and], Article 33 and Article 41;
Social Services Law §§364, 364-a, 364-j)

Sec.
599.1 Background and intent.
599.2 Legal base.
599.3 Applicability.
599.4 Definitions.
599.5 Certification.
599.6 Organization and administration.
599.7 Rights of recipients.
599.8 Clinic services.
599.9 Staffing.
599.10 Treatment planning.
599.11 Case records.
599.12 Premises.
599.13 Medical assistance clinic reimbursement system.
599.14 Medical assistance billing standards.
599.15 Indigent care.

§ 599.1 Background and intent.

(a) This Part establishes standards for the certification, operation and reimbursement of clinic treatment programs serving adults and clinic treatment programs serving children. 

(b) Clinic treatment programs serving adults serve individuals 18 years of age and older with a diagnosis of mental illness.  Clinic treatment programs serving children serve individuals up to 21 years of age and may include 21-year old individuals while such individuals are currently [enrolled in] admitted to a clinic serving children with a diagnosis of emotional disturbance.  A clinic treatment program may serve both adults and children.

(c) The goals of a clinic treatment program that serves adults are to diagnose and treat an individual’s mental illness, to work with the individual in developing a plan of care designed to minimize symptoms and adverse effects of illness, maximize wellness, and promote recovery toward the achievement of life goals such as, but not limited to, education and employment.

(d) The goals of a clinic treatment program that serves children are early assessment and identification of childhood emotional disturbances, and engagement of the child and family in the development of a plan of care designed to minimize the symptoms and adverse effects of illness, maximize wellness, assist the child in developing a resilient and hopeful approach to school, family, and community, and maintain the child in his or her natural environment.

(e) It is the intent of the Office of Mental Health that the goals described in this section be achieved through the establishment and operation of programs that provide outreach to address the symptoms and adverse effects of mental illness at their earliest stages, to avoid mental health crises where possible, and to respond in a timely and effective manner to such crises when they occur.  It is the intent of the Office to establish the clinic treatment program as a clinical home for the individual being served that provides a person-centered, recovery oriented and individualized approach to care.  Providers should utilize high quality and evidence-based practices and other practices which are supported by scientific research or generally accepted clinical practice guidelines to maximize individuals’ abilities[,]; to minimize the symptoms, adverse effects and consequences of mental illness[,]; to maintain and promote the individuals’ integration into the community[,]; to support family integrity; and to provide ongoing support to service recipients and their relevant collaterals. 

(f) This Part supersedes Part 85 of this Title as it relates to clinic treatment services operated by or under the auspices of the Office of Mental Health.

(g) This Part supersedes [inconsistent provisions of] Parts 587, [and] 588 and 592 of this Title as they relate to clinic treatment services operated by or under the auspices of the Office of Mental Health, except where specifically noted in this Part.

§ 599.2 Legal base.

(a) Sections 7.09 and 31.04 of the Mental Hygiene Law grant the Commissioner of Mental Health the power and responsibility to adopt regulations that are necessary and proper to implement matters under his or her jurisdiction, and to set standards of quality and adequacy of facilities, equipment, personnel, services, records and programs for the rendition of services for adults diagnosed with mental illness or children diagnosed with emotional disturbance, pursuant to an operating certificate.

(b) Section 31.02 of the Mental Hygiene Law prohibits the operation of outpatient programs providing services for persons with mental illness unless an operating certificate has been obtained from the Commissioner.

(c) Sections 31.07, 31.09, 31.13 and 31.19 of the Mental Hygiene Law further authorize the Commissioner or his or her representatives to examine and inspect such programs to determine their suitability and proper operation. Section 31.16 authorizes the Commissioner to suspend, revoke or limit any operating certificate, under certain circumstances.

(d) Section 31.11 of the Mental Hygiene Law requires every holder of an operating certificate to assist the Office of Mental Health in carrying out its regulatory functions by cooperating with the Commissioner in any inspection or investigation, permitting the Commissioner to inspect its facility, books and records, including recipients' records, and making such reports, uniform and otherwise, as are required by the Commissioner.

(e) Section 31.06 of the Mental Hygiene Law requires every holder of an operating certificate to develop policies and training programs in regard to reporting child abuse or neglect.

(f) Section 43.02(b) of the Mental Hygiene Law authorizes the Commissioner to request from operators of facilities licensed by the Office of Mental Health such financial, statistical and program information as the Commissioner may determine to be necessary.

(g) Article 33 of the Mental Hygiene Law establishes basic rights of persons diagnosed with mental illness.

(h) Section 364-j of the Social Services Law requires the establishment of managed care programs throughout the State and provides for the provision of special care services to enrollees in Medicaid managed care programs who require such services.

(i) Sections 364 and 364-a of the Social Services Law give the Office of Mental Health responsibility for establishing and maintaining standards for medical care and services in facilities under its jurisdiction, in accordance with cooperative arrangements with the Department of Health.

(j) Section 43.01 of the Mental Hygiene Law gives the Commissioner authority to set rates for outpatient services at facilities operated by the Office of Mental Health. Section 43.02 of the Mental Hygiene Law provides that payments under the medical assistance program for outpatient services at facilities licensed by the Office of Mental Health shall be at rates certified by the Commissioner of Mental Health and approved by the Director of the Budget.

(k) Title XIX of the Federal Social Security Act, as identified in section 502.2(c) of such Title, authorizes Federal grants to states to fund medical assistance to needy persons in accordance with a State plan approved by the Federal Department of Health and Human Services.

(l) Article 41 of the Mental Hygiene Law gives the Local Governmental Unit the authority to direct and administer a local comprehensive planning process for its geographic area in which all providers of service shall participate and cooperate through the development of integrated systems of care and treatment for persons with mental illness. 

(m) Section 41.13 of the Mental Hygiene Law establishes the powers and duties of the Local Governmental Unit.

§ 599.3 Applicability.

(a) This Part applies to any provider of service that operates or proposes to operate a clinic in which staff is assigned on a regular basis to provide services for the treatment of adults with a diagnosis of mental illness or children with a diagnosis of emotional disturbance.

(b) This Part applies to Clinic Treatment Programs, Diagnostic and Treatment Centers and hospital-based clinics, as defined in this Part. 

(c) This Part does not apply to the following activities which do not require an operating certificate issued by the Office:

(d) Medicaid reimbursement of outreach services and off-site services is contingent upon Federal approval. [This Part and all other standards of Medical Assistance reimbursement applicable to clinics shall be effective contingent upon Federal financial participation.]

(e) Programs which provide medical services, other than health monitoring and health screening, that comprise more than five percent of total annual visits shall also be licensed by the Department of Health.

§ 599.4  Definitions.  For purposes of this Part:

(a) After hours means before 8 a.m., [after] 6 p.m. or later, or during weekends.

(b) Ambulatory Patient Groups (APGs) means a defined group of outpatient procedures, encounters or ancillary services grouped for payment purposes.  The groupings are based on the intensity of the services provided and the medical procedures performed.   

(c) Base rate means the numeric value that shall be multiplied by the weight for a given service to determine the Medicaid fee for a service.

(d) Clinic treatment program means a program licensed as a clinic treatment program under Article 31 of the Mental Hygiene Law.

(e) Clinical services contract means a written agreement between the governing authority of an existing or proposed provider of services and another organization separate from the provider of services for the purpose of obtaining some of the clinical services or some of the clinical staff necessary to operate the program in compliance with requirements for an operating certificate.

(f) Clinical staff means staff members who provide services directly to recipients, including licensed staff, non-licensed staff, and student interns.

(g) Clinician means a person who is a member of the professional staff.

(h) Collateral means a person who is a member of the recipient’s family or household, or [a significant] other individual who regularly interacts with the recipient and is directly affected by or has the capability of affecting his or her condition, and is identified in the treatment plan as having a role in treatment and/or is necessary for participation in the evaluation and assessment of the recipient prior to admission.  A group composed of collaterals of more than one recipient may be gathered together for purposes of goal-oriented problem solving, assessment of treatment strategies and provision of practical skills for assisting the recipient in the management of his or her illness.

[(h) ](i) Commissioner means the Commissioner of the New York State Office of Mental Health.

[(i) ](j) Community education means activities designed to increase community awareness of the manifestations of mental illness and emotional disturbance and the benefits of early identification and treatment.

[(j) ](k) Complex care management means an ancillary service to psychotherapy or crisis intervention services.  It is provided by a clinician in person or by telephone, with or without the client.  It is a clinical level service which is required as a follow up to psychotherapy or crisis service for the purpose of preventing a change in community status or as a response to complex conditions.

[(k) ](l) Crisis intervention means activities, including medication and verbal therapy, designed to address acute distress and associated behaviors when the individual’s condition requires immediate attention. 

[(l) ](m) Current Procedural Terminology (CPT) means codes used in a coding system for health care procedures as defined in the publication Current Procedural Terminology which is published by the American Medical Association.

[(m) ](n) Designated mental illness means a disruption of normal cognitive, emotional, or behavioral functioning, which can be classified and diagnosed using the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) , other than:

[(n) ](o) Developmental testing means the administration, interpretation, and reporting of screening and assessment instruments for children or adolescents to assist in the determination of the individual’s developmental level for the purpose of facilitating the mental health diagnosis and treatment planning processes.

[(o) ](p) Diagnostic and treatment center for the purposes of this Part, means an outpatient program licensed as a diagnostic and treatment center [under]pursuant to Article 28 of the Public Health Law which provides more than 10,000 mental health visits annually, or for which mental health visits comprise over 30 percent of the annual visits.  A program providing fewer than 2,000 total visits annually shall not be considered a diagnostic and treatment center.

(q) Director of Community Services means the chief executive officer of the Local Governmental Unit.

[(p) ](r) Episode of service means a series of services provided during a period of admission.  An episode of service terminates upon completion of the treatment objectives or cessation of services.

[(q) ](s) Evidence-based treatment means an intervention for which there is consistent scientific evidence demonstrating improved recipient outcomes.

[(r) ](t) Family advisor means an individual who has experience, credentials, or training recognized by the Office and is or has been the parent or primary caregiver of a child with emotional, behavioral or mental health issues.

[(s) ](u) Health monitoring means the continued measuring of specific health indicators associated with increased risk of medical illness and early death.  For adults, these indicators include, but are not limited to, blood pressure, body mass index (BMI) , and smoking status.  For children and adolescents, these indicators include, but are not limited to, BMI percentile, activity/exercise level, and smoking status.

[(t) ](v) Health physical means the physical evaluation of an individual, including an age and gender appropriate history, examination, and the ordering of laboratory/diagnostic procedures, as appropriate.

[(u) ](w) Health screening means the initial gathering and assessing of information concerning the recipient’s medical history and current physical health status (including physical examination and determination of substance use) for purposes of informing an assessment and determination of its [to determine] potential impact on [the]a recipient’s mental health diagnosis and treatment, and the need for additional health services or referral. 

[(v) ](x) Healthcare common procedure coding system (HCPCS codes) means a comprehensive, standardized coding and classification system for health services and products.

[(w) ](y) Homebound individuals means people who have been determined by a licensed clinician to have a physical and/or mental illness that prevents them from leaving their residence to access mental health services or for whom a physician determines that leaving the residence to access mental health services would be detrimental to their  health or mental health.

[(x) ](z) Hospital-based clinic means an outpatient program licensed solely under Article 28 of the Public Health Law which is located in a general hospital and provides more than 10,000 mental health visits annually, or for which mental health visits comprise over 30 percent of the annual visits.  A program providing fewer than 2,000 total visits annually shall not be considered a hospital-based clinic.

[(y) Impairment in functioning due to emotional disturbance means a child has experienced functional limitations due to emotional disturbance over the past six months or more on a continuous or intermittent basis.  The functional problems must be moderate in at least two of the following areas, or severe in at least one of the following areas:

(z) ](aa) Initial assessment means a face-to-face interaction between a clinician and recipient and/or collaterals to determine the appropriateness of the recipient for admission to a clinic, the appropriate mental health diagnosis, and the development of a treatment plan for such recipient.

[(aa) ](ab) Injectable psychotropic medication administration means the process of preparing, administering, and managing the injection of intramuscular psychotropic medications.  It includes consumer education related to the use of the medication, as necessary.

[(ab) ](ac) Limited permit means that the New York State Education Department has determined that permit holders have met all requirements for licensure except those relating to the professional licensing final examination, and that pending licensure limited permit holders are functioning under proper supervision as outlined in the New York State Education Department law governing each of the professions.

[(ac) ](ad) Linkage with primary care means [services] activities designed to promote coordination, continuity and efficiency of mental health services and primary care services received by the recipient [the integration of the clinic and the primary care provider].

[(ad) ](ae) Local governmental unit (LGU) means the unit of local government authorized in accordance with Article 41 of the Mental Hygiene Law to provide and plan for local or unified services.

[(ae) ](af) Mental health screening for children means a broad-based approach to identify children and adolescents with emotional disturbances [and] in order to [intervene] allow for intervention at the earliest possible opportunity.

[(af) ](ag) Modifiers means payment adjustments made to Medicaid fees for specific reasons such as billing for off-site services (within established limits) , services in languages other than English, and services delivered after hours.

[(ag) ](ah) Non-licensed staff means individuals 18 years of age or older who do not possess a license issued by the New York State Education Department in one of the clinic professional staff categories listed in this Part and who may not provide therapeutic mental health services, except as may be authorized in section 599.9 of this Part.  Non-licensed staff includes employees who have a life experience related to mental illness or have education and training in human services.

[(ah) ](ai) Office means the New York State Office of Mental Health.

[(ai) ](aj) Outreach means face-to-face services with an individual, or, in the case of a child, the child and/or family member(s) for the purpose of beginning or enhancing the engagement process, or reengaging with individuals who are reluctant to participate in services, or to promote early intervention to prevent a psychiatric crisis. 

[(aj) ](ak) Peer advocate means an individual with personal experience as a mental health recipient, who has training, credentials or experience recognized by the Office.

[(ak) ](al) Peer group mean a grouping of providers sharing similar features such as geography or auspice. 

[(al) ](am) Physician fee schedule means a payment schedule established by the Department of Health which is used to enhance the payment for specific services included in this Part.

[(am) ](an) Preadmission status means the status of an individual who is being evaluated to determine whether he or she is appropriate for admission to the clinic.

[(an) ](ao) Preadmission visit means visits provided prior to [enrollment in] admission to clinic services.

(ap) Primary clinician is a member of the professional staff responsible for the development and implementation of the treatment plan.

[(ao) ](aq) Professional staff means practitioners possessing a license or a permit from the New York State Education Department who are qualified by credentials, training, and experience to provide direct services related to the [assessment and] treatment of mental illness and shall include the following:

[(ap) ](ar) Psychiatric assessment means an interview with [a] an adult [consumer,] or child or his or her[,] family member[,] or other collateral, performed by a psychiatrist or nurse practitioner in psychiatry, or physician assistant with specialized training approved by the Office[,].  An assessment [which] may occur at any time during the course of treatment, for the purposes of diagnosis, treatment planning, medication therapy, and/or consideration of general health issues.  A psychiatric assessment may also include on-site psychiatric consultation which includes an evaluation, report or interaction between a psychiatrist or nurse practitioner in psychiatry or physician assistant with specialized training approved by the Office and a referring physician for the purposes of diagnosis, integration of treatment and continuity of care.

[(aq) ](as) Psychiatric consultation means a face-to-face evaluation, [including] which may be in the form of video tele-psychiatry, of a consumer by a psychiatrist or nurse practitioner in psychiatry, including the preparation, evaluation, report or interaction between the psychiatrist or nurse practitioner in psychiatry and another referring physician for the purposes of diagnosis, integration of treatment and continuity of care.

[(ar) ](at) Psychological testing means a psychological evaluation using standard assessment methods and instruments to assist in mental health assessment and the treatment planning processes.

[(as) ](au) Psychotherapy means therapeutic communication and interaction for the purpose of alleviating symptoms or dysfunction associated with an individual’sdiagnosed mental illness or emotional disturbance, reversing or changing maladaptive patterns of behavior, encouraging personal growth and development, and supporting the individual’s capacity to achieve age-appropriate developmental milestones.

[(at) ](av) Psychotropic medication treatment means monitoring and evaluating target symptom response, ordering and reviewing diagnostic studies, writing prescriptions and consumer education as appropriate.

[(au) ](aw) Quality improvement means a systematic and ongoing process for measuring and assessing the performance of clinic services and for conducting initiatives and taking action to improve safety, effectiveness, timeliness, person centeredness or other aspects of services.

[(av) ](ax) Satellite means a physically separate adjunct site to a certified clinic treatment program, which provides either a full or partial array of outpatient services on a regularly and routinely scheduled basis (full or part time) . 

(ay) Serious emotional disturbance means a child or adolescent has a designated mental illness diagnosis according to the most current Diagnostic and Statistical Manual of Mental Disorders (DSM) and has experienced functional limitations due to emotional disturbance over the past 12 months on a continuous or intermittent basis. The functional limitations must be moderate in at least two of the following areas or severe in at least one of the following areas:

[(aw) ](az) Specialty clinic means a [clinics] clinic designated by the Commissioner as specializing in the provision of services to children who have a designated mental illness diagnosis and an impairment in functioning due to serious emotional disturbance.

[(ax) ](ba) Supplemental payment means payments in addition to the service fee amount. 

(bb) Treatment planning is an ongoing process of assessing the mental health status and needs of a recipient, establishing his or her treatment and rehabilitative goals and determining what services may be provided by the clinic to assist the individual in accomplishing these goals.

[(ay) ](bc) Visit means an interaction consisting of one or more procedures occurring between a recipient and/or collateral and the clinic staff on a given day.

[(az) ](bd) Weight means a numeric value that reflects the relative expected average resource utilization for each service as compared to the expected average resource utilization for all other services.

§ 599.5  Certification.

(a) A provider of service intending to operate a clinic treatment program must obtain an initial operating certificate issued by the Office in accordance with procedures established in Part 551 of this Title. Renewals of such operating certificates shall be issued for terms of up to three years.

(b) Each clinic site shall be authorized by a separate operating certificate. The operating certificate shall specify for each site:

(c) Each clinic authorized by an operating certificate pursuant to this Part shall be clearly identifiable. Each clinic shall have sufficient program space to provide safety, and to allow for a reasonable degree of privacy consistent with the effective delivery of services [which shall ensure privacy and safety].  Program space may be shared with other programs, pursuant to a plan approved by the Office.  Non-program space, e.g., waiting rooms, restrooms, etc., may be shared with other programs.  

(d) Clinics may provide services at off-site locations.

(e) Off-site locations which are determined by the Office to be satellite locations of a primary program shall meet the following requirements:

(f) Establishment of a new program or changes to the operating certificate requires prior approval of the Office in accordance with Part 551 of this Title.

(g) Changes in the hours of operation of a program may be made upon notification to the Office and the Office's determination that the changes will not negatively affect the program, consistent with the provisions of Part 551 of this Title.

(h) An operating certificate may be limited, suspended or revoked by the Office pursuant to Part 503 of this Title. The operating certificate is the property of the Office and as such shall be returned to the Office if it should be revoked.

(i) The provider of service shall frame and display the operating certificate within the clinic treatment program site in a conspicuous place which is readily accessible to the public.

(j) The provider of service shall cooperate with the Office or the local governmental unit during any review or inspection of the clinic treatment program.

(k) The county director of community services shall be responsible for identifying specific licensed clinic treatment programs that may be designated by the Commissioner as specialty clinic programs serving children in accordance with the identified need within the county.  In making such identifications, the county director of community services shall use the criteria specified in Part 587 of this Title.

(l) A clinic treatment program designated by the Office as a [children’s] specialty clinic serving children shall be authorized to [provide, and] be reimbursed by Medicaid on a fee-for-service basis for providing[,] clinic treatment services to children with a serious emotional disturbance up to but not including their 19^th birthday, notwithstanding the child’s enrollment in a Medicaid managed care program.

(m) The Commissioner shall have the authority to designate and approve demonstration projects for purposes of examining innovative program and administrative configurations, regulatory flexibility and alternative funding methodologies. 

§599.6 Organization and administration.

(a) The provider of service shall identify a governing body which shall have overall responsibility for the operation of the program. The governing body may delegate responsibility for the day-to-day management of the program to appropriate staff pursuant to an organizational plan approved by the Office.

(b) In programs operated by not-for-profit corporations other than hospitals licensed pursuant to Article 28 of the Public Health Law, no person shall serve both as a member of the governing body and of the paid staff of the clinic treatment program without prior written approval of the Office.

(c) The governing body shall be responsible for the following duties:

(d) A provider of service shall ensure that no recipient who is otherwise appropriate for admission [recipient] is denied access to services solely on the basis of having a co-occurring non-mental health diagnosis, or a diagnosis of HIV infection, AIDS, or AIDS-related complex.

(e) The provider of service shall establish mechanisms to ensure that priority access is given to individuals referred to the provider, who are enrolled in an assisted outpatient treatment program established pursuant to section 9.60 of the Mental Hygiene Law , in accordance with the following[.]:

(f) The provider of service shall establish mechanisms for the meaningful participation of recipient and/or family representatives either through direct participation on the governing body, or through the creation of a recipient advisory board. If a recipient advisory board is used, the provider of service shall ensure a mechanism for the recipient advisory board to make recommendations to the governing body.

(g) The provider of service shall develop and make available to recipients and collaterals, a plan which will assure an appropriate response to recipients [enrolled in] admitted to the program and their collaterals who need assistance when the program is not in operation. Such plan shall include the ability to speak with a member of the licensed staff of the clinic or a licensed staff person working under the auspices of the clinic pursuant to a plan approved by the local governmental unit or, for county-operated providers, by the Office.

(h) A provider of service shall ensure that any clinic subject to this Part does not:

(i) A provider of service shall ensure that recipient participation in research only occurs in accordance with applicable Federal and State requirements.

(j) A provider of service shall ensure the development, implementation and ongoing monitoring of a Risk Management Program that includes the requirements for identification, documentation, reporting, investigation, review, and monitoring of incidents pursuant to the Mental Hygiene Law and Part 524 of this Title.

(k) There shall be an emergency evacuation plan and staff shall be knowledgeable about its procedures.

(l) There shall be a written utilization review procedure to ensure that all recipients are receiving appropriate services and are being served at an appropriate level of care.  Such policies and procedures shall include provisions ensuring that utilization review is performed, at a minimum, on a random 25 percent sample of [recipients] open cases, and shall be performed only by professional staff trained to do such reviews, or by staff who are otherwise qualified by virtue of their civil service standing, and shall ensure to the maximum extent possible that the designated utilization review authority functions independently of the clinical staff that is treating the recipient under review. Such utilization review procedure shall provide for:

(m) The provider of service shall participate as requested by the local governmental unit in the local planning processes pursuant to Article 41 of the Mental Hygiene Law.

(n) The provider of service shall cooperate with the Office and the local governmental unit in monitoring the access to services of individuals or groups determined to be in urgent need of services pursuant to this section.

(o)  In programs that are not operated by State government, there shall be an annual audit of the service provider, pursuant to a format prescribed by the Office, and in accordance with Generally Accepted Auditing Principles, of the financial condition and accounts of the provider, or in accordance with requirements established by the Department of Health for programs operated by agencies operated pursuant to Article 28 of the Public Health Law.  This audit shall be performed by a certified public accountant who is not a member of the governing body or an employee of the program. In addition, the provider is required to submit an annual Consolidated Fiscal Report to the Office of Mental Health, signed by the Chief Executive Officer, and meet all requirements for submission as described in the instructions for this Report.  Government-operated programs shall comply with applicable laws concerning financial accounts and auditing requirements.

§ 599.7  Rights of recipients.

(a) Recipients admitted to a clinic treatment program certified pursuant to this Part are entitled to the rights defined in this subdivision. A provider of service shall be responsible for ensuring the protection of these rights.  

(b) A provider of service shall provide a notice of recipients' rights as described in subdivision (a) of this section to each recipient upon admission to a clinic treatment program. Such notice shall be provided in writing and posted in a conspicuous location easily accessible to the public. The notice shall include the address and telephone number of the Commission on Quality of Care and Advocacy for Persons with Disabilities, the nearest regional office of the Protection and Advocacy for Mentally Ill Individuals Program, the nearest chapter of the Alliance on Mental Illness of New York State and the Office of Mental Health.

§ 599.8 Clinic services.

(a) Eligibility for admission to a clinic treatment program shall be based on a designated mental illness diagnosis.

(b) Clinic treatment programs shall offer each of the following services, to be provided consistent with recipients’ conditions and needs:

(c) Clinics may offer the following optional services:

(d) A clinic treatment program that has been approved to be a Child and Family Clinic-Plus provider shall also provide the following services:

§ 599.9 Staffing.

(a) A provider of service shall continuously have an adequate number and appropriate mix of staff to carry out the objectives of the clinic treatment program and to assure the outcomes of the program. The provider shall have a staffing plan that documents the staff qualifications, including training, clinical experience with adults diagnosed with mental illness or children diagnosed with emotional disturbance, and supervisory experience in a clinical setting, the appropriateness of the mix of staff, the assignment of staff to the primary program site and any approved satellite locations, and the supervisory relationships among the staff.   The plan shall also detail any proposed use of students, or non-licensed staff, and their supervision and oversight. Such plan shall be subject to review and approval by the Office at the time of issuance or renewal of the program's operating certificate, and shall demonstrate sufficient coverage by qualified psychiatrists and medical staff to meet the needs of program enrollees.

(b) The following individuals may provide services, within their defined scopes of practice or as otherwise permitted by law:

(c) All clinic staff of providers licensed solely under Article 31 of the Mental Hygiene Law who are directly involved in providing services shall submit to criminal background checks, and clearance by the New York Statewide Central Register of Child Abuse and Maltreatment.

(d) The Office may approve other qualified staff, as appropriate. 

(e) The Office may approve the transition of programs to heightened licensure requirements set by the New York State Education Department or other licensing or credentialing authority to the extent permitted by law.  

§ 599.10  Treatment planning.

(a) Treatment planning is an ongoing process of assessing the mental health status and needs of the individual, establishing his or her treatment and rehabilitative goals, and determining what services [can] may be provided by the clinic to assist the individual in accomplishing these goals.   The treatment planning process includes, where appropriate, a means for determining when the individual’s goals have been met to the extent possible in the context of the program, and planning for the appropriate discharge of the individual from the clinic.  The treatment planning process is a means of reviewing and adjusting the services necessary to assist the individual in reaching the point where he or she can pursue life goals such as employment or education, without impediment resulting from his or her illness.

(b) The treatment plan shall include identification and documentation of the following:   

[(e) ] (c) The treatment plan for recipients receiving services reimbursed by Medicaid on a fee-for-service basis shall be signed by a psychiatrist or other physician, and shall include a projected schedule for service delivery and the projected frequency and duration of each type of planned therapeutic session or encounter.

[(c) ] (d) The treatment plan for recipients reimbursed by any other payer for whom the program prescribes psychotropic medication shall be signed by a psychiatrist, other physician or nurse practitioner in psychiatry.

[(d) ] (e) The treatment plan for recipients reimbursed by any other payer who do not receive psychotropic medication shall be signed by a psychiatrist, other physician, licensed psychologist, nurse practitioner in psychiatry, or licensed clinical social worker.  

(f) Recipient participation in treatment planning shall be documented by the signature of the recipient or the signature of the person who has legal authority to consent to health care on behalf of the recipient, or, in the case of a child, the signature of a parent, guardian, or other person who has legal authority to consent to health care on behalf of the child, as well as the child, where appropriate, provided, however, that the lack of such signature shall not constitute noncompliance with this requirement if the reasons for non-participation by the recipient are documented in the treatment plan. [Reasons for non-participation and/or a refusal to sign by the recipient, parent, guardian, or person who has legal authority to consent to health care, shall be documented in the case record.]  The recipient's family and/or collaterals may participate as appropriate in the development of the treatment plan. Collaterals participating in the development of the treatment plan shall be specifically identified in the plan.

(g) Treatment plans shall be completed not later than 30 days after admission, or for services provided to a recipient enrolled in a managed care plan which is certified by the Commissioner of the Department of Health or commercial insurance plan which is certified or approved by the Superintendent of the Insurance Department, pursuant to such other plan’s requirement as shall apply.

(h) The treatment plan shall include, where applicable, documentation of the need for the provision of off-site services, special linguistic arrangements, [complex care management,] or determination of homebound status. 

(i) Treatment plans shall be reviewed and updated as necessary based upon the recipient’s progress, changes in circumstances, the effectiveness of services, or other appropriate considerations. Such reviews shall occur no less frequently than every 90 days, or the next [scheduled] provided service, whichever shall be later. For services provided to a recipient enrolled in a managed care plan which is certified by the Commissioner of the Department of Health or commercial insurance plan which is certified or approved by the Superintendent of the Insurance Department, treatment plans may be reviewed pursuant to such other plan requirement as shall apply.  Treatment plan reviews shall include the input of relevant staff, as well as the recipient, family members and collaterals, as appropriate.  

(j) The periodic review of the treatment plan shall include the following:

(k) Progress notes shall be recorded by the clinical staff member(s) who provided services to the recipient upon each occasion of service. These notes must summarize the service(s) provided, update the recipient’s progress toward his or her goals, and include any recommended changes to the elements of the recipient’s treatment plan.  The progress notes shall also document the date and duration of each service provided, the location where the service was provided, whether collaterals were seen, and the name and title of the staff member providing each service. The need for complex care management and the actions taken by the clinic in response to this need shall also be recorded in the progress notes.

§ 599.11 Case records.

(a) There shall be a complete case record maintained for each person admitted to a clinic. Such case records shall be maintained in accordance with recognized and accepted principles of recordkeeping as follows:

(b) The case record shall be available to all staff of the clinic who are participating in the treatment of the recipient and shall include the following information:

(c) The discharge summary shall be transmitted to the receiving program, where applicable, prior to the arrival of the recipient, or within two weeks, whichever comes first. When circumstances interfere with a timely transmittal of the discharge summary, notation shall be made in the record of the reason for delay. In such circumstances, a copy of all clinical documentation shall be forwarded to the receiving program, as appropriate, prior to the arrival of the recipient.

(d) When a recipient is transferred between programs offered by the same provider, a consolidated record format that follows the recipient may be used.

(e) Records must be retained for a minimum period of six (6) years from the date of the last service in an episode of service.

(f) Information in clinic case records that is subject to the confidentiality protections of Mental Hygiene Law Section 33.13 may be shared between facilities, agencies and programs responsible for the provision of services pursuant to an approved local or unified services plan (including programs that receive funding from the Office disbursed via a State Aid letter) ; the Office and any of the psychiatric centers and programs that it operates; and facilities, agencies, and programs that are not licensed by the Office and are not participants in an approved local or unified services plan, but are responsible for the provision of services to any patient pursuant to a written agreement with the Office as a party, provided, however, if a case record contains HIV or AIDS information that is protected by Public Health Law Article 27-F, or information provided by a federally-funded alcoholism/substance abuse provider that is protected under 42 CFR Part 2, such information shall only be redisclosed as permitted by such law or regulation.

§ 599.12  Premises.

(a) A provider of service shall maintain premises that are adequate and appropriate for the safe and effective operation of a clinic program in accordance with the following:

(b) The provider of service shall ensure life safety on the premises by possession of a certificate of occupancy in accordance with the Building Code of New York State and the Property Maintenance Code of New York State (19 NYCRR Chapter XXXIII, Subchapter A, Parts 1221 and 1226) or comparable local codes.   

§ 599.13 Medical assistance clinic reimbursement system.

(a) Reimbursement for clinic treatment procedures will be fee based.                   

(b) A weight for each clinic procedure shall be established by the Office which reflects the relative anticipated resource utilization for such procedure.  For some procedures, fees shall be enhanced pursuant to Section 599.14 of this Part through the use of billing modifiers for such things as procedures delivered off-site, after hours, services provided in languages other than English, and services of a minimum duration of 15 continuous minutes delivered by a physician or nurse practitioner in psychiatry.   

(c) Providers will be categorized into peer groups pursuant to this section.  The Office will establish a base fee for reimbursement for each peer group.  Such fee shall be reduced by 25 percent during the period in which any such provider retains an operating certificate with a duration of less than six months as a result of having been determined to be deficient in meeting applicable standards and requirements, pursuant to this Part.

(d) Peer group specific base fees may be adjusted as applicable by the Office.  Provider specific fee adjustments may be made to reflect pay for performance enhancements, penalties resulting from the Office inspection and certification process, or for other reasons described in the regulations of the Office.

(e) Payments for procedures will be determined by multiplying the assigned weight for the appropriate procedure code set forth at 10 NYCRR Part 86 by the base fee, and adjusting such fee for modifiers and discounts, as appropriate. When a modifier or discount is expressed as a percentage, it will adjust the payment by its percentage of the [peer group base rate] procedure weight.  When more than one [modifier or discount applies to a] procedure applies to a visit, the highest value procedure shall be paid at its full fee value[, they shall be summed before being applied to the base rate].  Payments for additional procedures related to the visit will be discounted by 10 percent.

(f) The Office will annually review procedure weights, modifier values, peer groupings and the base fees for each of the peer groupings, and will update them as needed.  Any changes will be published in the State Register and posted on the Office’s website.

(g) The Office will establish and make public a list of weights associated with all CPT and HCPCS procedure codes which can be used to bill specific mental health clinic procedures through Medical Assistance. The Office will update this list as needed.

(h) Providers licensed solely under Article 31 of the Mental Hygiene Law shall be classified by the following peer groups.  During the transition to the reimbursement methodology established in this Part, the [The] fee paid to new clinics, or clinics commencing service in a new county, shall be equal to that of the lowest blended rate in the appropriate peer group.

(i) Hospital-based providers licensed under Article 28 of the Public Health Law and Article 31 of the Mental Hygiene Law shall be classified by the following peer groups. The base rates will be calculated pursuant to 10 NYCRR Part 86.

(j) Diagnostic and treatment center (D&TC) providers licensed under Article 28 of the Public Health Law and Article 31 of the Mental Hygiene Law shall be classified by the following peer groups.  The base rates will be calculated pursuant to this Part.  During the transition to the reimbursement methodology established in this Part, the [The] fee paid to new clinics, or clinics commencing service in a new county, shall be equal to that of the lowest blended rate in the appropriate peer group.

(k) D&TCs and hospitals – Where a corporation operates a hospital and a D&TC, the Office will determine the primary relationship between the mental health clinic and the hospital or D&TC and assign the clinic to the appropriate peer group.

(l) Supplemental Payments:

(m) System Transition. During the transition, the procedures indicated in the table following as Full Procedures shall be reimbursed at the full payment described in (e) of this section, subject to the discount for multiple procedures related to a visit.  For all other procedures, there will be a transition to full procedure based reimbursement.  During the transition, payment for such procedures will consist of a blended payment comprised of a legacy portion of the fees established under Part 588 and Part 592 of this Title and the procedure payment established under Part 599.  For such procedures, the blended payment will be calculated as follows:

§ 599.14 Medical Assistance billing standards.

(a) Medicaid claims for individuals who have been admitted to a clinic treatment program shall include, at a minimum, the Medicaid identification number of the recipient, the designated mental illness diagnosis, the procedure code or codes corresponding to the procedure or procedures provided, the location of the service, specifically the licensed location where the service was provided or the clinician’s regular assigned licensed location from which the clinician departed for an off-site procedure, and the National Provider Identification or equivalent Department of Health-approved alternative as appropriate of the attending clinician.  The provider must also [document in the individual’s service record compliance] comply with the requirements associated with any procedure code being billed.

(b) Medicaid claims may be [submitted] reimbursed for up to three pre-admission procedures per adult recipient, no more than one of which may be a collateral procedure.  For children, claims may be [submitted] reimbursed for up to three pre-admission visits.  [Each such visit may include an individual service, a collateral service, or both.]  Such claims shall include, at a minimum, the Medicaid identification number of the recipient, the designated mental illness diagnosis, the procedure code or codes corresponding to the procedure or procedures provided, the location of the service, specifically the licensed location where the service was provided or the clinician’s regular assigned licensed location from which the clinician departed for an off-site procedure, and the National Provider Identification or equivalent Department of Health-approved alternative as appropriate of the attending clinician.  For pre-admission visits at least the code for diagnosis-deferred must be entered on the claim. 

(c) Medicaid claims may be submitted for no more than two services per day for any individual, not including crisis, injectable psychotropic medication [management] administration, psychotropic medication treatment, and health care services.

(d) Billing services:

(e) Modifiers:

(f) A clinic may not be reimbursed for services provided to an individual currently enrolled in another licensed mental health outpatient program for which Medicaid reimbursement is being made, except as provided in this subdivision.

(g) The Office will only consider requests for revisions of fees calculated under the provisions of this Part due to errors made by the Office in its calculation. 

(h) Miscellaneous billing rules.

§ 599.15 Indigent care.

(a) The indigent care program for clinics has been established by New York State to offset a portion of the losses from uncompensated care experienced by diagnostic and treatment centers licensed by the New York State Department of Health and mental health clinics licensed by the Office that are not also licensed by the New York State Department of Health and/or not directly operated by the Office.

(b) Eligible mental health clinics for purposes of this section shall mean non-profit or county-sponsored clinics that can demonstrate losses from a disproportionate share of uncompensated care during a base period two years prior to the grant period; with the exception of the transition period to be established by the Office in guidance.

(c) Uncompensated care need, for purposes of this section, means the following, subject to limitations to be provided in guidance by the Office:

(d) To be eligible for an allocation of funds pursuant to this section, a mental health clinic must demonstrate that a minimum of five percent of total clinic visits reported during the applicable base year period meet the eligibility requirements for the pool.  For clinics operated by an agency that operates more than one clinic, to be eligible for an allocation of funds pursuant to this section, the agency must demonstrate that a minimum of five percent of its total clinic visits meets these requirements.  To be eligible, clinics must further demonstrate that they maintain a sliding fee scale for uninsured individuals.

(e) Documentation of uncompensated care need must be retained by the clinic and will be subject to an audit by the New York State Office of the Medicaid Inspector General or other party empowered to conduct such audits.

(f) Rules for the reporting of data on uncompensated care visits to the Office will be established in guidance.  Providers participating in the uncompensated care pool that do not submit annual data by dates to be established by the Office will be excluded from the pool for that year.

(g) A mental health clinic qualifying for a distribution pursuant to this section shall provide assurances satisfactory to the Commissioners of Health and Mental Health that it shall undertake reasonable efforts to maintain financial support from community and public funding sources and reasonable efforts to collect payments for services from third-party insurance payers, governmental payers and self-paying patients.

(h) To be eligible for reimbursement pursuant to this section, claims must be consistent with the Medical Assistance billing standards set forth in this Part.  Payments from the indigent care pool [are] shall be made in accordance with the payment rules established by the Office and the Department of Health.

(i) The allocations of funds to a mental health clinic may be reduced if the Office determines that provider management actions or decisions have caused a significant reduction for the grant period in the delivery of mental health services to uncompensated care residents of the community.

(j) After a transition period established by the Office in guidance, the value of uncompensated care payments are based on the average APG peer group Medicaid payment for the second year prior, less expected client payments.

599.TEXT with changes.6.29.10

Comments or questions about the information on this page can be directed to the Bureau of Policy, Regulation and Legislation.