| PHL Article 28 Licensed Provider |
- Currently, a provider licensed under PHL Article 28 and offering mental health services –meaning a general hospital outpatient department or a diagnostic and treatment center (primary care provider) – and which has more than 2,000 total visits per year must be licensed under Article 31 of the Mental Hygiene Law (MHL) by OMH if it has more than 10,000 annual visits for mental health services or more than 30 percent of its total annual visits are for mental health services.
- A primary care provider may not provide substance use disorder services without being certified by OASAS pursuant to MHL Article 32.
- Consistent with section 2807(2– a)(f)(ii)(c) of the Public Health Law (PHL), Medicaid reimbursement is available for individual mental health counseling services provided by a licensed clinical social worker (LCSW) or a licensed master social worker (LMSW) under the supervision of a LCSW, psychologist or psychiatrist in PHL Article 28 licensed outpatient hospital clinics (OPDs) and freestanding diagnostic and treatment centers (D&TCs), including school based health centers (SBHCs). Such services, however, are reimbursable only when provided to enrollees under the age of 21 and to pregnant women up to 60 days postpartum (based on the date of delivery or end of pregnancy). In order to qualify as a billable Medicaid service, claims for services rendered to pregnant women are required to have a primary or secondary diagnosis of pregnancy and claims for services rendered to women post–pregnancy are required to have a primary or secondary diagnosis of postpartum depression.
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- A practitioner providing mental health and/or substance use disorder services in a DOH licensed clinic must be a licensed psychiatrist, psychologist, psychiatric nurse practitioner, or an LCSW.
- Licensed mental health counselors, licensed marriage and family therapists, and PhD staff are not recognized providers in the PHL Article 28 licensed setting.
- Providers integrating services under the DSRIP 3.a.i Licensure Threshold should submit one claim for each visit with all the procedures/services rendered on the date of service (e.g., behavioral health services and primary care services). The Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment.
- Consistent with section 2807(2– a)(f)(ii)(c) of the Public Health Law (PHL), Medicaid reimbursement is available for individual mental health counseling services provided by a licensed clinical social worker (LCSW) or a licensed master social worker (LMSW) under the supervision of a LCSW, psychologist or psychiatrist in PHL Article 28 licensed outpatient hospital clinics (OPDs) and freestanding diagnostic and treatment centers (D&TCs), including school based health centers (SBHCs). Such services, however, are reimbursable only when provided to enrollees under the age of 21 and to pregnant women up to 60 days postpartum (based on the date of delivery or end of pregnancy). In order to qualify as a billable Medicaid service, claims for services rendered to pregnant women are required to have a primary or secondary diagnosis of pregnancy and claims for services rendered to women post–pregnancy are required to have a primary or secondary diagnosis of postpartum depression.
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- When a provider believes its volume of services will approach the threshold limits, a provider has the option of integrating services by either seeking a second license for a particular site or integrating services under the integrated outpatient services regulations. Providers may not bill Medicaid for any service rendered above the licensure threshold amount unless the appropriate licensure or certification is in place at the time the service was rendered.
- A licensed or certified provider approved under the integrated outpatient services regulations to provide integrated care services will be issued an integrated services rate code that will reimbursed through the APGs
- Medicaid is always the payer of last resort. Providers must bill all commercial insurance prior to billing Medicaid. Medicaid will pay the lower of the third party patient responsibility or the difference between the third party paid amount and the integrated services APG rate.
- Approved integrated services providers are assigned APG Medicaid billing rate codes which are to be used by the integrated services provider at the host site.
- A primary care host model provider approved to provide integrated care services may bill for behavioral health services provided by a nurse practitioner. Note: Nurse Practitioner may not bill Medicaid for professional services provided in an Article 28.
- A primary care host model provider approved to deliver mental health services is reimbursed through APGs. The APG grouper reimburses for individual and group psychotherapy.
- Consistent with section 2807(2– a)(f)(ii)(c) of the Public Health Law (PHL), Medicaid reimbursement is available for individual mental health counseling services provided by a licensed clinical social worker (LCSW) or a licensed master social worker (LMSW) under the supervision of a LCSW, psychologist or psychiatrist in PHL Article 28 licensed outpatient hospital clinics (OPDs) and freestanding diagnostic and treatment centers (D&TCs), including school based health centers (SBHCs). Such services, however, are reimbursable only when provided to enrollees under the age of 21 and to pregnant women up to 60 days postpartum (based on the date of delivery or end of pregnancy). In order to qualify as a billable Medicaid service, claims for services rendered to pregnant women are required to have a primary or secondary diagnosis of pregnancy and claims for services rendered to women post–pregnancy are required to have a primary or secondary diagnosis of postpartum depression.
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- When a provider believes its volume of services will approach the threshold limits, a provider has the option of integrating services by either seeking a second license for a particular site or integrating services under the integrated outpatient services regulations. Providers may not bill Medicaid for any service rendered above the licensure threshold amount unless the appropriate licensure or certification is in place at the time the service was rendered.
- Population limits placed on Medicaid reimbursement for mental health counseling provided by LCSWs or LMSWs are not applicable to dually licensed clinics.
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| PHL Article 28 Licensed Provider (FQHC) |
- Population limits placed on Medicaid reimbursement for mental health counseling provided by LCSWs or LMSWs are not applicable to federally designated health clinics (Federally Qualified Health Center (FQHC), FQHC "look–alike", or Rural Health Clinic (RHC)).
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- FQHCs that have not opted into APGs operate under the PPS (Prospective Payment System) rate. Federally designated health clinics must bill their all–inclusive PPS rate for individual therapy and a lesser rate per recipient for group therapy.
- No regulatory waiver of 10 NYCRR § 86–4.9 will be provided to allow for reimbursement of two visits on one day.
- DOH sets the PPS rate using the methodology established under federal law. The PPS methodology, including the "per visit basis," is established under federal law and DOH does not have the authority to waive federal rules.
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| MHL Article 31 Licensed Provider |
- Currently, a provider licensed by OMH under MHL Article 31 to provide outpatient mental health services must obtain PHL Article 28 licensure by DOH if more than 5 percent of total annual visits are for primary care services or if any visits are for dental services.
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- New rate codes are being established to allow an MHL Article 31 licensed provider to bill for the provision of primary care services under the DSRIP Project 3.a.i. Licensure Threshold construct.
- Providers integrating services under the DSRIP 3.a.i Licensure Threshold should submit one claim for each visit with all the procedures/services rendered on the date of service (e.g., behavioral health services and primary care services). The Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment. (see Integrated Services FAQ, question #69, for specific codes)
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- When a provider believes its volume of services will approach the threshold limits, a provider has the option of integrating services by either seeking a second license for a particular site or integrating services under the integrated outpatient services regulations. Providers may not bill Medicaid for any service rendered above the licensure threshold amount unless the appropriate licensure or certification is in place at the time the service was rendered.
- A licensed or certified provider approved under the integrated outpatient services regulations to provide integrated care services will be issued an integrated services rate code that will be reimbursed through APGs.
- Providers integrating services under the integrated outpatient services regulations should submit one claim for each visit with all the procedures/services rendered on the date of service (e.g., behavioral health services and primary care services). The Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment. (see Integrated Services FAQ, question #69, for specific codes)
- Medicaid is always the payer of last resort. Providers must bill all commercial insurance prior to billing Medicaid. Medicaid will pay the lower of the third party patient responsibility or the difference between the third party paid amount and the integrated services APG rate.
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- When a provider believes its volume of services will approach the threshold limits, a provider has the option of integrating services by either seeking a second license for a particular site or integrating services under the integrated outpatient services regulations. Providers may not bill Medicaid for any service rendered above the licensure threshold amount unless the appropriate licensure or certification is in place at the time the service was rendered.
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| MHL Article 32 Certified Provider |
- Currently, a provider certified by OASAS under MHL Article 32 to provide outpatient substance use disorder services must obtain PHL Article 28 licensure by DOH if more than 5 percent of total annual visits are for primary care services or if any visits are for dental services.
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- Providers integrating services under the DSRIP 3.a.i Licensure Threshold should submit one claim for each visit with all the procedures/services rendered on the date of service (e.g., behavioral health services and primary care services). The Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment.
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- When a provider believes its volume of services will approach the threshold limits, a provider has the option of integrating services by either seeking a second license for a particular site or integrating services under the integrated outpatient services regulations. Providers may not bill Medicaid for any service rendered above the licensure threshold amount unless the appropriate licensure or certification is in place at the time the service was rendered.
- A licensed or certified provider approved under the integrated outpatient services regulations to provide integrated care services will be issued an integrated services rate code that will reimbursed through the APGs.
- Providers integrating services under the integrated outpatient services regulations should submit one claim for each visit with all the procedures/services rendered on the date of service (e.g., behavioral health services and primary care services). The Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment. (see Integrated Services FAQ, question #69, for specific codes)
- Medicaid is always the payer of last resort. Providers must bill all commercial insurance prior to billing Medicaid. Medicaid will pay the lower of the third party patient responsibility or the difference between the third party paid amount and the integrated services APG rate.
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- When a provider believes its volume of services will approach the threshold limits, a provider has the option of integrating services by either seeking a second license for a particular site or integrating services under the integrated outpatient services regulations. Providers may not bill Medicaid for any service rendered above the licensure threshold amount unless the appropriate licensure or certification is in place at the time the service was rendered.
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