BILL NUMBER:  S6511

 TITLE OF BILL :  An act to amend the social services law, in relation
to medical assistance payments for clinical services provided to
persons with a traumatic brain injury

 PURPOSE :

The purpose of this bill is to restore the full payment amounts for
patients with traumatic brain injury to the same amount that are
received for developmentally disabled patients in Article 28 clinics
after the Medicare payment is deducted.

 SUMMARY OF PROVISIONS :

Section 1 of the bill includes patients with traumatic brain injury as
well as those with developmental disabilities to Section 367-a of the
social services law to clarify that article 28 facilities serving both
groups of patients who also have Medicare coverage should be
reimbursed at the same rate by Medicaid.

Section 2 provides an effective date.

 JUSTIFICATION :

Individuals with a traumatic brain injury (TBI) and those with
              

developmental disabilities (DD) have been treated similarly with
regard to Article 28 clinic services and reimbursement for many years.
Both have a Recipient Exception (RE) Code (code 95 for DD and 81 for
TBI) and both (1) receive an enhanced payment under Article 28
Medicaid APGs; (2) are included in the exemption for Medicaid therapy
caps; and (3) get paid up to the Medicaid rate for nonparticipating
Commercial Insurance.

However, due to a 2012 statutory change and a 2013 federal Medicare
settlement (the Jimmo Settlement), clinic services for TBI patients
are no longer paid the balance up to the Medicaid rate after the
Medicare payment.

Because Medicare does not have a clinic rate and only pays a much
lower physician practice rate, Article 28 clinics that serve TBI
patients are losing 20 -30% of what even Medicaid would reimburse on
every TBI patient visit. This additional 20-30% reimbursement cut
threatens the fiscal viability of Article 28 clinics that are often
the only health care providers for individuals with disabilities and
other Medicaid patients. Therefore, in order to preserve both the
fiscal viability of these clinics and access to healthcare services
for these vulnerable New Yorkers, this bill would authorize clinics to
receive payments up to the Medicaid rate for all TBI and DD patients.

 LEGISLATIVE HISTORY :

New bill

 FISCAL IMPLICATIONS :

A very small fiscal amount statewide to be determined as rates are
restored to this small population in certain article 28 settings.

 EFFECTIVE DATE :
Immediately.