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OPTS Background Information

04/10/12

In 2004, the New York State Office of Mental Retardation and Developmental Disabilities (which is now called the Office for People With Developmental Disabilities) implemented a new program called Options for People Through Services, or NYS OPTS, designed to afford individuals receiving services as well as the public and nonprofit providers who care for them with a wide array of affordable options that promote inclusion and personal choice and offer flexibility and opportunity for efficient and effective use of the resources we have available to us.

  1. Key Information about the OPTS program:

    • Participation in NYS OPTS is voluntary.
    • OPWDD will hold the single Provider Agreement with Medicaid.
    • Voluntary providers will continue to hold Operating Certificates for programs that will be certified and funded through OPWDD.
    • While OPWDD will be the provider of record, the agency will subcontract for service provision through voluntary providers. The terms of any subcontract will be detailed in an agreement that will be entered into by OPWDD and the voluntary provider.
  2. NYS OPTS Steering Committee

    To assist OPWDD in the implementation of this major initiative and to assure that the NYS OPTS direction is a collaborative one, a Steering Committee to participate in the creation, development, implementation and monitoring of the new NYS OPTS program was formed. This Steering Committee and its three corresponding Subcommittees (the Consumer and Family, Provider and Implementation Subcommittees) are comprised of a broad cross-section of individuals who participate in the service system, including parents and family members, individuals who are receiving services, providers, local government, state staff, and other representatives. The involvement of the Steering Committee assures that the development of the OPTS program represents all those who have a stake in the service system.

  3. Guiding Principles

    To accomplish our mission and realize our vision of moving to an organized health care delivery system, we will be guided by the OPTS Guiding Principles to assure that we meet the needs of individuals who have mental retardation and developmental disabilities and their families.

    NYS OPTS will:

    • Maximize opportunities for individual choice through person-centered services.
    • Advance independence, inclusion and individual and family responsibility throughout the system.
    • Preserve oversight systems to ensure the highest quality of services for all individuals.
    • Assure that all providers promote the health, safety and protection of individuals through compliance with the highest standards of operation.
    • Improve access to needed services and supports for eligible individuals.
    • Enhance flexibility within the service system.
    • Promote user-friendly efficient and effective operations.
    • Encourage continued participation and open communication among all those involved in the system.
  4. NYS OPTS Agreement

    The form and format of the OPTS agreements between OPWDD and its voluntary providers of service has been finalized, the principal elements of these agreements will be as follows:

    NYS OPTS Agreement - Expectations:

    The voluntary provider will:

    • Provide authorized service(s) as an independent contractor.
    • Maintain in good order required operating certificates, licenses, permits or authorizations for such services. Arrange to have OPWDD appear as an additional insured on liability insurance.
    • Complete enrollment documents and ensure consumers remain eligible for Medicaid (consumers must apply for Medicaid and have a documented diagnosis of a developmental disability).
    • Comply with all documentation and reporting requirements.
    • Complete and submit required forms and registration documents, notify the OPWDD of third party payers, submit timely claims and be prohibited from billing MMIS directly or indirectly for any services delivered under this Agreement.
    • When necessary, adjust and resubmit any billing documents.
    • Cooperate with the OPWDD in ensuring that consumers receive high quality services and that a person-centered planning process is used that is appropriate to each individual’s planning needs.
    • Keep all consumer records confidential.
    • Provide services requiring an operating certificate in a facility that complies with the certification requirements.

    The OPWDD will:

    • Operate the NYS OPTS Program so long as all necessary federal or state approvals are in place (if the NYS DOH or the federal government makes changes that require a change to this Agreement and the provider does not agree to the changes, OPWDD may cancel this Agreement).
    • Determine the appropriate level of funding and pay the provider on a timely basis.
    • Make payments to the provider and funding-level adjustments as indicated in the Agreement.
    • Have the right to recover funds improperly billed by the provider.
    • Reserve the right to recoup amounts due to the OPWDD from OPWDD programs operated by the provider but not covered by the Agreement.
    • Upon cancellation, pay the provider for all valid claims submitted.

    Other Expectations:

    • The Agreement will conform to the provisions of the federal regulations at 42 CFR 434.6.
    • The provider and OPWDD may cancel the Agreement in accordance with NYS Appendix A (standard terms and conditions for all NYS contracts).
    • OPWDD may cancel the Agreement immediately if the life or safety of consumers is jeopardized or if a required operating certificate is revoked.
    • Cancellations are conditional upon the formulation of an acceptable transition plan.
    • The term of the Agreement shall be five years with the right to renew.
  5. Methodology to Determine Provider Payment Levels Under OPTS

    The chart that follows identifies the key components of the NYS OPTS funding methodology. The methodology was developed based upon a consideration of the need of the methodology to address funding streamlining and provider stability issues.

    Methodology Elements

    Provider Fiscal Issue Addressed

    1. Operating Base
      Based upon direct service hours (direct care/support and related fringe)
    • Funding streamlining
    • Payment approval acceleration
    1. Fee Add-Ons
      To include Clinical Oversight and approved Clinical staff, OPTS and Administration. Would provide mechanism for inclusion for funding enhancements.
    • Funding streamlining
    • Funding enhancement
    • Payment approval acceleration
    1. Property & Equipment
      Reimbursed separately from operating. OPWDD payment of 1/12 of annual amount each month. Debt service (new facilities) to be amortized rather than depreciation based. Property & Equipment reimbursement will be updated annually.
    • Cash Flow
    • Funding streamlining
    • Stability & predictability
    1. Requests for Increases
      Processed by Central Office. DDSO support will be necessary. Surplus/deficit will not be performed; however, CFRs will be periodically reviewed and cost rebasing may be implemented.
    • Funding streamlining
    • Cash Flow
    • Stability & predictability

    NYS OPTS Billing and Payment System

    The following bullets describe the highlights of the NYS OPTS payment system. The enhancement of provider cash flow is an essential element of the system

    NYS OPTS Payment System

    Providers Report Service Information to OPWDD

    • Providers can submit electronic files with service information, or
    • Providers can report services using a simple web-based application (like SEMP).

    OPWDD Processes Payments to Providers

    • Based on the services the provider reports, OPWDD will send an electronic voucher to OSC.
    • As soon as OPWDD transmits the voucher to OSC, the provider can see remittance reports on the web. These reports will tell the provider the amount of OSC payment to expect.
    • Within 5 business days, OSC will issue payment to the provider.

    OPWDD Will Submit Claims to Medicaid for OPTS Services

    • OPWDD will submit HIPAA-compliant billing to Medicaid based on the provider’s service reporting.
    • OPWDD will work with providers regarding any Medicaid claims that are affected by consumer eligibility issues.

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Created on Tuesday, 10 Apr 2012 at 8:46 am.

Last updated on Thursday, 6 Nov 2014 at 5:52 pm.