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May 20, 2020

COVID-19: OPWDD Updates Billing Guidance for Certain Providers

This serves as an update to our prior alert about the Office for People With Developmental Disabilities (OPWDD)’s Day Service Retainer Program and related billing guidance. This phase of the Day Service Retainer Program is effective for day habilitation and prevocational services as of April 16, whereas billing guidance for community habilitation is effective as of March 18.

Elimination of Concept of Enhanced Rates for Supervised Individualized Residential Alternatives (IRAs)

While the OPWDD previously released draft enhanced rates for IRA services, it announced that those rates will not be used at this time.

Service recipients who were previously identified for enhanced residential habilitation rates can be additionally billed under Group Community Habilitation-R (CH-R); this category of billing only includes those residing in a supervised IRA of one agency who traditionally received day habilitation and prevocational services at a different provider agency. This does not apply to individuals who may have participated in other programming, including supported employment (SEMP). While additional guidance on this type of billing is forthcoming, the OPWDD stated Group CH-R billing is only to be used for those weekdays in which a services recipient attended another agency’s day habilitation or prevocational services.

Provider Qualifications and Billing for Retainer Payments

Like before, to participate in the program, providers must meet certain qualifications and agree to terms set forth in an attestation written by the OPWDD. Among other things, providers must agree to be productive by offering and providing support to those in need as well as participating in shared staffing agreements with at least one other agency, demonstrating the providers will use or provide staff pursuant to the agreement where needed and available.

Retainer payments will continue to be based upon 80 percent of the average monthly paid claims per provider per individual from July 2019 through December 2019 for day habilitation, prevocational, and community habilitation services. If a provider offers all three services, the retainer payment will be equal to 80 percent of the total aggregate monthly revenue for those services. A provider may “earn” the additional 20 percent of payments by delivering productive services pursuant to its mission.

For each service, a provider will have a limit on the retainer units it can bill and a cap of total units. Provider agencies will have an allocated number of retainer units for each service based on 80 percent of the average monthly paid claims for the period July 2019 through December 2019. The state will notify providers of the maximum number of retainer and service units combined that may be billed each month for each service. The provider will then bill eMedNY for both retainer and service units.

For community habilitation, if a provider’s agency delivers day habilitation or site-based prevocational services, the agency may exceed the monthly service and retainer unit limit for community habilitation only in cases where the additional units support people living at home who formerly attended the provider’s site-based program, and the monthly revenue associated with all of the provider’s day services does not exceed 100 percent of the monthly average for the 2019 period, with appropriate adjustments for intervening rate actions.

In most cases, the OPWDD instructs providers to bill either a service unit or retainer unit on a given day, but not both. Retainer units are for individuals who cannot be served or who can only be served in a minimal capacity. One exception is that a provider may bill a full retainer unit of day habilitation or prevocational services and no more than two hours of community habilitation for a person who resides at home.

For school-age children and young adults who would have been in school but for COVID-19, community habilitation may be temporarily delivered during weekday, daytime hours to students authorized to receive those services. This allows community habilitation to be provided during what would have been part of the school day up to the amount previously authorized for that individual.

The OPWDD reminds providers that all payments are subject to a regular reconciliation process and should not exceed aggregate historical billings for day habilitation, prevocational services, and community habilitation. If a provider chooses to participate in the Day Service Retainer Program, it must include all eligible services that it provides, including day habilitation, prevocational services, and community habilitation.

Provision of Services

The OPWDD also warns that duplication of services and retainer units is precluded, as eMedNY billing edits will remain in effect. Moreover, retainer units must be billed for services in accordance with the schedule that would have been provided to the particular services recipient. For example, if a provider delivered day habilitation services on a Monday-Wednesday-Friday schedule, retainer days must also be billed on that schedule. Further, if a person chooses a different provider and the different provider can support the person at the same level of service the person received prior to the emergency, the original provider may not bill additional retainer units. For community habilitation retainer billing, eMedNY will require that the provider “roll up” all community habilitation units delivered to a person on a given day.

Regarding day services for individuals residing in supervised IRAs, providers will receive an additional payment for people who participated in day habilitation or prevocational services from another agency by billing to Group CH-R. A supervised IRA, however, may not bill Medicaid for both day-service retainer units and the authorized number of CH-R units on the same day. If the residential provider delivers and bills Medicaid for CH-R to reflect the day-time staffing needs of a person who participated in a different agency’s day services, the day-service provider is eligible to bill retainer units (not service units) according to the individual’s schedule for day services prior to COVID-19.

The OPWDD continues to encourage day services to be temporarily delivered by telehealth to maintain social distancing, and prior approval is not needed as long as the recipient and their family are comfortable with the telehealth delivery method. Providers are also allowed to provide and bill Medicaid for services that support the individual and their family while maintaining social distancing. For these services, providers may bill for the time staff spend traveling to the individual’s home and from the staff member’s home as well as the time spent running the errand.

Service Authorization

If an agency opts into the Day Service Retainer Program, the provider has the flexibility to offer day habilitation, community habilitation, or prevocational services to meet the needs of the individuals they currently serve without seeking authorization through the Developmental Disability Regional Office (DDRO) or submitting a Developmental Disability Profile (DDP)-1. These agencies may also offer these services to address a crisis situation for someone they are presently serving without the need for DDRO authorization or a DDP-1 submission.

Conversely, the following categories of individuals must go through the normal process for service authorization through the DDRO:

  1. Those new to the OPWDD and for whom eligibility has not yet been established
  2. An OPWDD-eligible individual who is not currently home and community based (HCBS)-waiver enrolled and is now requesting HCBS waiver enrollment and services
  3. Individuals transitioning into the community from specialized waiver-ineligible settings such as developmental centers, prisons, nursing homes, residential schools, or intermediate care facilities
  4. Individuals transitioning from local schools. In these instances, a DDP-1 submission will be required once an appropriate service provider is identified.

Updates to life and staff action plans will be facilitated using an email form sent to the care coordination organization with a copy to the DDRO. An individual’s current life and staff action plans must remain in place until changes can be made in accordance with additional COVID-19 guidance from the OPWDD. Prior updates to life and staff actions plans will not be needed for services delivered through the Day Service Retainer Program. The OPWDD noted more information will be forthcoming regarding documentation expectations related to life and staff action plans.

Retainer Billing

Claims may be submitted to eMedNY once the signed attestation is received by the OPWDD. Retainer units may be billed retroactive to March 18 for community habilitation and April 16 for day habilitation and prevocational services. Those retainer claims submitted without a signed attestation will be subject to recovery.

Providers will need to include Revenue Code 0180 on claim submissions to indicate “leave of absence.” All other claim identifiers will remain the same. Retainer billing units are currently under development by the Department of Health. Monthly limits for retainer units and total limits of retainer and service units combined will be provided for each agency participating in the program.

The OPWDD intends to distribute the attestation in the coming weeks, at which point the state will distribute monthly and total limits for retainer and service units. The attestation must then be returned to the OPWDD to participate.

In light of evolving logistics, we continue to strongly advise providers that utilize this program to thoroughly document compliance with each of the requirements set forth by the OPWDD. Barclay Damon will continue to update providers as new development arise.

If you need any assistance regarding these new rules, please contact Melissa Zambri, Health Care & Human Services Practice Area Co-Chair, at mzambri@barclaydamon.com; Mary Connolly, associate, at mconnolly@barclaydamon.com; or another member of the firm’s Health Care & Human Services Practice Area.

We also have a specific team of Barclay Damon attorneys who are actively working on assessing regulatory, legislative, and other governmental updates related to COVID-19 and who are prepared to assist clients. Please contact Yvonne Hennessey, COVID-19 Response Team leader, at yhennessey@barclaydamon.com or any member of the COVID-19 Response Team at COVID-19ResponseTeam@barclaydamon.com.

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