Additional Guidance Letter

  • Letter are also available in Portable Document Format (PDF)

March 22, 2021

Dear Provider:

This letter provides information regarding changes in reimbursement enacted through a regulatory amendment to 18 NYCRR § 505.28(j), which was issued in final on January 13, 2021 and in accordance with statutory authority in Sections 363-a(2) & 365-f of the Social Services Law and Section 201(1)(v) of the Public Health Law. This change applies to Fiscal Intermediaries (FIs) performing administrative services under the Consumer Directed Personal Assistance Program (CDPAP).

Effective April 1, 2021, the Department will implement a three-tier Per Member Per Month (PMPM) rate structure for reimbursement of the administrative services component for CDPAP-. The three tiers will be based on the number of direct care hours authorized per member per month. The Tiers are as follows:

Tier Number of Direct Care Hours
Authorized Per Month Per Consumer
FI PMPM Reimbursement
1 1 – 159 hours $145
2 160 – 479 hours $384
3 480 hours and above $1,036

The provider-specific direct care medical services component of the rate has been modified to remove the FI administrative costs consistent with the changes above, and is posted for your information here. The guidelines for billing and reimbursement of administrative services are set forth in Attachment A and eMedNY billing guidance has been updated consistent with these changes. Nothing in this letter impacts wages or wage related requirements for CDPAP personal assistants, including State law or regulatory requirements related to minimum wage, overtime pay, or wage parity, where applicable.

If you have any questions regarding the above information, please send an email to PersonalCare-Rates@health.ny.gov for questions on the rates or ConsumerDirected@health.ny.gov for questions on the policy, and the Department will respond to your inquires.

Sincerely,

Ann Foster

Deputy Director
Division of Finance & Rate Setting
Office of Health Insurance Programs

Attachment


ATTACHMENT A

CDPAP Fiscal Intermediary Reimbursement Effective April 1, 2021

  • Current Reimbursement for Consumer Directed Personal Assistance Program (CDPAP) administrative services is included in the Total Final Rate and billed through Medicaid rate codes. Effective April 1, 2021, the Department will remove the administrative component for CDPAP rates for FFS.
  • Effective April 1, 2021, the Department will implement a three-tier Per Member Per Month (PMPM) rate structure for Fiscal Intermediary (FI) services as defined in state law for FI services provided to Medicaid recipients enrolled in CDPAP. The CDPAP Administrative Claim must be submitted on or after the first day of the month immediately following the month for which reimbursement is being claimed.
  • FIs will bill a separate administrative rate code (below) for each Approved/Authorized consumer once per each month that the FI is providing service to that consumer based on the greatest number of direct care hours authorized in that month by the LDSS. The rate structure and billing codes for administrative reimbursement will be active in eMedNY next week and will be as follows:
Tier Number of Direct Care Hours
Authorized Per Month Per Consumer
FI PMPM Reimbursement Rate Codes
1 1 – 159 hours $145 8400
2 160 – 479 hours $384 8401
3 480 hours and above $1,036 8402
  • Providers shall continue to utilize current provider-specific CDPAP rate codes for the direct care medical services component as they have in the past.