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August 31, 2020

COVID-19: NYS OPWDD Adds Flexibility for Certain Day Service Providers After Retainer Program Termination

On August 25, the NYS Office for People With Developmental Disabilities (OPWDD) held a webinar discussing temporary modifications for day habilitation and site-based prevocational providers following the OPWDD’s termination of the Day Service Retainer Program on July 21. The changes are applicable to day services provided from July 22 through October 14 and largely modify the billing and program duration standards for day habilitation and site-based prevocational services providers.

While these flexibilities are available, the OPWDD emphasized that they aren’t required and encouraged providers to assess whether an adoption of the modifications would be beneficial for any particular agency.

Modified Billing Standards

Under the modifications, the OPWDD changed program-duration requirements for day services—a full unit requires a program duration of at least two hours whereas a half unit requires a program duration of at least one hour. Full and half units of service billed that don’t meet the pre-COVID-19 standards for program duration must be billed using the revenue code 0249.

Moreover, the OPWDD modified program standards to allow the program duration to include face-to-face service time, time when staff are engaged with the individual using remote telehealth delivery (in accordance with COVID-19 telehealth guidance), and mealtimes. As of August 24, the OPWDD’s April 24 guidance in which day habilitation providers were allowed to provide and bill Medicaid for certain services while maintaining social distancing has been rescinded. Providers are no longer allowed to include, as part of program duration, staff time spent traveling to the person’s home, providing essential non-face-to-face services, and returning to the worker’s home or office.

Further, from July 22 through August 23, providers may use either the flexibilities to include non-face-to-face service time or the modified program-duration requirements. Claims that use both will be subject to disallowance.

Billing Adjustments

If a provider submitted claims for day habilitation services since July 22 and an adjustment is needed due to the revised guidance, providers must adjust the claims within 60 days from August 25. The adjustment process requires a new claim form to be submitted that references the transaction control number (TCN) of the claim with the adjustment field marked.

Daily Billing and Financial Limitations

For all day habilitation and site-based prevocational providers that opt to use the modified program-duration standards, the provider may bill no more than the following per individual per day:

  • One full unit of day habilitation or site-based prevocational services or
  • One half unit of day habilitation and one half unit of site-based prevocational services

Day habilitation and site-based prevocational providers should note billing for services using the modified program durations will subject them to the same limitations that were imposed as part of the Day Service Retainer Program: the total monthly number of units claimed for each service must not exceed the average monthly units for each service claimed from the period of July 1, 2019 through December 31, 2019. Moreover, the combined average monthly revenue for day habilitation and site-based prevocational services, community-based prevocational services, and community habilitation claimed by the provider may not exceed the provider’s combined average monthly revenue for those services for the same period.

Service Authorization

After July 21, providers who participated in the Day Service Retainer Program will continue to have the flexibility to offer day habilitation, community habilitation, and site-based prevocational services to meet the needs of an individual who they’re presently serving without having to seek additional authorization through the Developmental Disability Regional Office (DDRO) or submit a Developmental Disabilities Profile 1 (DDP-1) or DDP-1 Supplement. Providers may also offer these services to address a crisis situation for an individual who they’re presently serving without the need for DDRO authorization.

The COVID-19 addendum may be used to update the life and staff action plans through October 14. Providers should initiate any updates and send them to the care coordination organization’s (CCO) care manager. The care manager signs and distributes the updates to the individual services recipient and providers. Then, the care manager emails a copy to the OPWDD Central Operations.

If an agency has not opted into the Day Service Retainer Program, the care manager must seek DDRO authorization through the service amendment process to secure services. The individual’s life and staff action plans would also remain in place until changes are made in accordance with the OPWDD’s COVID-19 guidance.

Community Habilitation and Community-Based Prevocational Services

Certain flexibilities are also applicable to community habilitation and community-based prevocational services from July 22 through October 14. These flexibilities include the ability to provide services remotely via telehealth. In addition, individuals who live in a certified residence with less than 24-hour staffing may receive these services in the residence. Flexibilities regarding non-face-to-face services, including providing certain services while maintaining social distancing as described in the OPWDD’s April 24 guidance, will remain in place for these types of services.

Supervised IRA providers may also continue to deliver and bill eMedNY for group community habilitation (CH-R) provided to IRA residents who participated in day habilitation or prevocational services delivered by a different agency prior to the pandemic. Providers are reminded that claims for group CH-R may not be submitted on a day when an individual receives day habilitation or prevocational services.

Barclay Damon’s attorneys will continue to monitor changes implemented by the OPWDD to its programs during COVID-19. Providers are strongly encouraged to not only thoroughly document the type of service provided, but to also accurately document any adjustments submitted to eMedNY for day services rendered between July 22 and October 14.

If you need assistance navigating these new rules, please contact Susan Benz, Health Care & Human Services Practice Area co-chair, at sbenz@barclaydamon.com; Melissa Zambri, Health Care & Human Services Practice Area co-chair, at mzambri@barclaydamon.com; or Mary Connolly, associate, at mconnolly@barclaydamon.com.

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