Part 599 MHOTRS Program

Integrated Services

Regulations and Guidance

Standards of Care

Licensing

Fiscal/Billing

MHOTRS Program Resources

CCBHC Demonstration

School-Based Mental Health Clinics

***Revised July 1, 2010***

Sample Data Collection Chart

New York State has submitted a federal Medicaid waiver request to establish an uncompensated care funding pool for mental health clinics that is jointly funded by the state and federal government. Assuming the waiver is approved, the pool will offset a portion of losses from uncompensated care experienced by:

1. Diagnostic and Treatment Centers licensed by DOH; and
2. Mental health clinics licensed by OMH that are not affiliated with hospitals or directly operated by OMH.

Payments from the uncompensated care pool will be made in accordance with payment rules established by the OMH and DOH. Agencies that do not submit annual data for each of their clinic locations by the dates established by OMH will be excluded from the pool for that year.

Pending approval of the waiver request, periodic partial payments from the pool will be made by the Department of Health. After a transition period for mental health clinics (described below), payments from the pool will be based on annual data from two years prior.

The percent of uncompensated care paid by the pool is dependent on the total funds in the pool and the total volume of allowable uncompensated care visits. To be eligible for an allocation of funds from the pool, a mental health clinic must demonstrate that a minimum of five percent of total clinic visits during the applicable period were for visits covered by the uncompensated care pool.

Mental health clinics qualifying for a distribution from the fund will need to provide OMH with assurances that it undertook reasonable efforts to maintain financial support from community and public funding sources and made reasonable efforts to collect payments for services from third-party insurance payers, governmental payers and self-paying patients. This is subject to audit.

OMH anticipates that visits can be counted toward uncompensated care volume if they meet the following conditions:

1. Self pay, including partial pay or no pay visits (does not include partial payment associated with co-pays or deductibles).
2. Required or optional mental health clinic procedures (as defined in OMH regulations) provided but not covered under a clinic’s agreement with an insurer. The service must be provided by a practitioner qualified to deliver the service under state regulations.
3. Unreimbursed clinic visits/procedures appropriately provided to an insured recipient by a clinic staff member not approved for payment by a third party payor in contract with the clinic. The provider must document that the clinic or recipient received a denial of payment.
4. Unreimbursed clinic visits/procedures appropriately provided to an insured recipient by a clinic staff member when the procedure is not reimbursed by a third party payer not in contract with the clinic. Only visits for which the clinic received a denial of payment from the insurer or an attestation from the client/insured that the insurer made no payment will be considered uncompensated. This documentation 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.

Visits will not be counted if they meet the following conditions:

1. Visits paid in whole or part by a third party payer (including Medicaid Managed Care).
2. Visits not authorized (considered not medically necessary) by an insurer/managed care plan.
3. Visits provided to a recipient who has coverage from a third party payer not in contract with the clinic when an insurer does reimburse the insured for the visit.
4. Visits delivered by persons unqualified to deliver the services under state regulations.

Transition - Visit Value and Data Collection
The method of pricing uncompensated care visits and calculating uncompensated care volume will transition over time as follows:

Uncompensated Care Value:

1. In 2010, OMH will base uncompensated care reimbursement on the appropriate peer group Medicaid rate for a 45 minute psychotherapy procedure delivered by an LCSW.
2. In 2011, the uncompensated care pool rate will be based on the peer group average value of mental health clinic Medicaid APG payments (no blend)¹ for at least the first six months of 2010.
3. In 2012 and after, payments will be based on the current peer group average value of total Medicaid APG payments (no blend).

Uncompensated Care Volume:

1. Uncompensated care payments to Article 31 clinics during calendar year 2010 will be based on annualized uncompensated care visit volume and total care visit volume delivered July 1, 2009 through December 31, 2009.
2. Uncompensated care payments to Article 31 clinics during calendar year 2011 will be based on uncompensated care visit volume and total care visit volume for the period January 2010 through June 2010.
3. Uncompensated care payments to Article 31 clinics during calendar year 2012 will be based on data as follows:
   1. Payments to clinics in NYC will be based on data from July 09 through June 2010.
   2. Payments to clinics in the rest of the state will be based on data from calendar year 2010.

Reimbursement Calculation
Clinics must provide eligible uncompensated care visits equal to 5% of their visit volume to qualify for reimbursement from the pool. Reimbursement is then calculated according to the following schedule. Assuming sufficient funds in the pool, the first 15% of clinic visits (assuming they are uncompensated and qualify for reimbursement) are reimbursed at 50% of their Medicaid value minus self pay revenues received. The second 15% are reimbursed at 75% of their Medicaid value minus self pay revenues received. Eligible visits exceeding 30% are reimbursed at 100% of their Medicaid value minus self pay revenues received. A hypothetical example follows on the next page.

It is important to note that if the amount of eligible uncompensated care visits in the pool (D&TC and Article 31) exceeds the funding available in the pool the payments to providers will be proportionately reduced.

Supplemental Funding
Should money be made available to OMH, OMH may supplement the distribution providers receive from the joint DOH-OMH uncompensated care pool.

Hypothetical D&TC/Article 31 Uncompensated Care Pool Revenue Example

Total Clinic Visits	30,625
Uncompensated Visits	4,900
Uncompensated %	16%

If uncompensated % is >5% of total visit volume, the agency is eligible for uncompensated care revenue. If uncompensated % is <5% of total visit volume, the agency is not eligible for participation in the uncompensated care pool.

Eligible Costs

Uncompensated Visits	4,900
Medicaid Average Payment 2	$115.00
Uncompensated Cost Base	$ 563,500
Less: Self-Pay Revenues
Uncompensated Visits	4,900
Self-Pay Revenue Per Visit	$30.00
Self-Pay Revenues	$(147,000)
Eligible Uncompensated Cost Base	$ 416,500

Uncompensated Care Revenue Projection

Distribution %s	Uncompensated %	% Total	Payment %	Uncompensated Care Revenue
1st 15%	15%	93.75%	50%	$195,234
2nd 15%	1%	6.25%	75%	$19,523
> 30%	0%	0.00%	100%	$-
Total	16%	100.00%	xxx	$214,758

Sample Data Collection Chart
The following chart contains the fields of information required to submit visit volume data to OMH via the Mental Health Provider Data Exchange (MHPD).

Agency Name
Agency Code
Operating Certificate Number

	Total Visits	Revenue Earned By Payor
Payors
1 Medicare Only
2 Medicaid Fee-for-Service Only
3 Medicaid Managed Care Only
4 Medicaid Fee-for-Service and Medicare
5 Medicaid Managed Care and Medicare
6 Medicaid Fee-for-Service and Other Private Insurance
7 Medicaid Managed Care and Other Private Insurance
8 Child Health Plus or Family Health Plus
9 Other Private Insurance Only
10 Participant Fees- Co-pays and Deductibles
Uncompensated Care
11 Participant Fees and Accompanying Visits - Not Co-pays (Self-Pay)
12 Third Party – Not Paid – Non-covered services
13 Third Party – Not Paid – Non-Eligible Licensed Staff
14 Third Party – Not Paid – Non-Eligible Out of Network Services
15 Total Visits (Sum of lines 1-14)
16 Visits eligible for Uncompensated Care Reimbursement (Sum lines 11-14)
17 Uncompensated Care Visits (Line 16) as Percent of Total Visits (Line 15)

Instructions for the Data Collection Chart (This chart matches the data requirements of the CFR OMH-4.)
Mental health clinics licensed by OMH that are not affiliated with hospitals or directly operated by OMH must complete and submit this schedule in order to participate in the uncompensated care pool for 2010.

Visit volume data is based on date of service rendered.� Only count visits provided during the reporting period.� Revenue earned from either the participant or out-of-network insurer for a date of service within the submission period must be reported where indicated whether the revenue was received or not.� Providers will follow their GAAP process for writing-off uncollectibles.�

For the purposes of this schedule, a visit is defined as including all procedures provided to a patient on the same day.

Agency Name: The name of the organization (service provider).

Agency Code: The five-digit code assigned to the organization (service provider).

Operating Certificate Number: NYS OMH Outpatient Clinic License #

1. Enter total visits where Medicare was the only payor.
2. Enter total visits where Medicaid fee-for service was the only payor.
3. Enter total visits where Medicaid managed care was the only payor.
4. Enter total visits where Medicaid and Medicare were the only payors.
5. Enter total visits where Medicaid managed care and Medicare were the only payors.
6. Enter total visits where Medicaid and other private insurance were the only payors.
7. Enter total visits where Medicaid managed care and other private insurance were the only payors.
8. Enter total visits and revenue earned where Child Health Plus or Family Health Plus was the only payor.
9. Enter total visits where other private insurance was the only payor.
10. Enter total revenue earned from Participant Fees – Co-pays and Deductibles.
11. Enter total visits and revenue earned from Participant Fees – Not Co-Pays (Self-Pay).
12. Enter total visits where private insurance did not pay because the services provided were non-covered.
13. Enter total visits where private insurance did not pay because the services were provided by non-eligible staff.
14. Enter total visits where private insurance did not pay because the services were provided out-of-network.
15. Total visits (Sum of lines 1-14)
16. Visits eligible for uncompensated care reimbursement (Sum of lines 11-14)
17. Uncompensated care visits (line 16) as a percent of total visits. This line is filled in by MHPD. The percentage must be 5% or higher to be eligible for reimbursement from the pool.