A 11658: Establishes mandatory supplemental therapeutic services reimbursement for certain individuals receiving services through the office for people with developmental disabilities.

  
  STATE OF NEW YORK ________________________________________________________________________ 11658  IN ASSEMBLY July 29, 2026 ___________ Introduced by COMMITTEE ON RULES -- (at request of M. of A. Wieder) -- read once and referred to the Committee on People with Disabilities AN ACT to amend the mental hygiene law and the public health law, in relation to establishing a mandatory supplemental therapeutic services reimbursement for individuals receiving services through the office for people with developmental disabilities The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. The mental hygiene law is amended by adding a new section 2 16.36 to read as follows: 3 § 16.36 Supplemental therapeutic services reimbursement. 4 1. Notwithstanding any inconsistent provision of law, rule or regu- 5 lation, the commissioner shall, upon application and upon satisfaction 6 of the criteria set forth in subdivision three of this section, author- 7 ize supplemental reimbursement for therapeutic services for an eligible 8 individual when such services: (a) have been determined to be medically 9 necessary; (b) are included in an approved service plan, plan of care, 10 or other authorized planning document; and (c) cannot be secured within 11 twenty-one days despite documented reasonable efforts to obtain such 12 services at state-established reimbursement rates. 13 2. For purposes of this section, "therapeutic services" shall mean 14 counseling, psychotherapy, behavioral therapy, or other clinically 15 appropriate therapeutic intervention provided by a person who is 16 licensed, certified, or otherwise legally authorized under the laws of 17 this state to furnish such service. 18 3. Supplemental reimbursement under this section shall be approved 19 upon a determination by the commissioner, or the commissioner's desig- 20 nee, that: 21 (a) the service is medically necessary and included in an approved 22 planning document; 23 (b) the eligible individual or the individual's authorized represen- 24 tative, in coordination with the relevant care manager, service coordi- 25 nator, or other responsible planning entity, made documented reasonable 26 efforts over a period of not less than twenty-one days to obtain the EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD15849-02-6 
 A. 11658 2 1 service from a provider willing to accept the applicable state-establ- 2 ished reimbursement rate, and such efforts were unsuccessful; 3 (c) delay or absence of such service would materially impair the indi- 4 vidual's health, behavioral stability, community functioning, or mainte- 5 nance in the least restrictive setting appropriate to such individual's 6 needs; and 7 (d) the provider selected to furnish the service is appropriately 8 licensed, certified, or otherwise legally authorized under the laws of 9 this state. 10 4. Upon approval under subdivision three of this section, the commis- 11 sioner shall authorize reimbursement in an amount equal to seventy-five 12 percent of the provider's billed charges, subject to the following: 13 (a) The minimum supplemental reimbursement floor shall be one hundred 14 twenty dollars per hour for individual therapy sessions, ninety dollars 15 per hour for group therapy sessions, and one hundred fifty dollars per 16 hour for behavioral intervention or applied behavior analysis (ABA) 17 services. Such reimbursement floors shall not be reduced by regulation 18 or administrative action. 19 (b) Beginning January first, two thousand twenty-eight, and annually 20 thereafter, the minimum reimbursement floors set forth in paragraph (a) 21 of this subdivision shall be increased by the same percentage as the 22 medical care component of the Consumer Price Index for All Urban Consum- 23 ers (CPI-U) for the New York metropolitan area for the preceding calen- 24 dar year, as published by the United States Bureau of Labor Statistics. 25 Such annual adjustment is mandatory. 26 (c) The maximum reimbursement shall not exceed two hundred fifty 27 dollars per hour for individual therapy, one hundred seventy-five 28 dollars per hour for group therapy, and three hundred twenty-five 29 dollars per hour for ABA services, subject to the same annual CPI-U 30 adjustment described in paragraph (b) of this subdivision. 31 5. The commissioner shall act on a complete application for supple- 32 mental reimbursement under this section within fifteen business days of 33 receipt. Failure to act within such period shall constitute approval of 34 the application by operation of law. The commissioner shall provide 35 written notice to the applicant within five business days of a determi- 36 nation, including the basis for any denial. 37 6. To the extent any therapeutic service authorized under this section 38 is or may be reimbursable under the New York state Medicaid program, 39 including any applicable waiver or managed care arrangement, the commis- 40 sioner shall coordinate implementation of this section with the depart- 41 ment of health to ensure compliance with applicable federal Medicaid 42 requirements. No supplemental reimbursement shall be authorized in a 43 manner that would jeopardize federal financial participation or violate 44 any applicable federal statute, regulation, or waiver condition. 45 7. Any individual or authorized representative who is denied supple- 46 mental reimbursement under this section, or who does not receive a 47 determination within the timeframe required by subdivision five of this 48 section, may seek administrative review pursuant to applicable proce- 49 dures under the mental hygiene law and may file a complaint with the 50 office of the Medicaid inspector general. The commissioner shall main- 51 tain a dedicated intake process for complaints arising under this 52 section and shall respond in writing within ten business days. 53 8. The commissioner shall promulgate regulations necessary to imple- 54 ment this section within ninety days of enactment, including standards 55 governing: (a) documentation of provider unavailability at state-establ- 56 ished reimbursement rates during the twenty-one day period required 
 A. 11658 3 1 under subdivision three of this section; (b) verification of medical 2 necessity; (c) allowable service categories; (d) prior authorization and 3 utilization review procedures; and (e) audit and program integrity meas- 4 ures. 5 § 2. Section 32 of the public health law is amended by adding a new 6 subdivision 25-a to read as follows: 7 25-a. practices related to supplemental therapeutic services 8 reimbursement authorized pursuant to section 16.36 of the mental hygiene 9 law for the purpose of detecting fraud, waste, abuse, or improper 10 payment, to the same extent as other payments made with state or Medi- 11 caid funds; 12 § 3. On or before December first next succeeding the effective date of 13 this act, and annually thereafter, the commissioner of the office for 14 people with developmental disabilities shall publish on the office's 15 website and submit to the governor, temporary president of the senate 16 and speaker of the assembly, a report setting forth, for the preceding 17 year: (a) the number of applications received; (b) the number approved 18 and denied; (c) the general reasons for denial in aggregate form; (d) 19 the types of services approved; (e) average and aggregate reimbursement 20 amounts; (f) the number of applications approved by operation of law due 21 to the commissioner's failure to act within fifteen business days; and 22 (g) a summary of access-related outcomes. No personally identifiable 23 information shall be included in such report. 24 § 4. Nothing in this act shall be construed to create an entitlement 25 to any therapeutic service beyond amounts appropriated therefor, to 26 alter underlying program eligibility standards, to require the state to 27 revise any generally applicable reimbursement methodology outside the 28 limited circumstances set forth herein, or to create any private right 29 of action. 30 § 5. This act shall take effect on the ninetieth day after it shall 31 have become a law. Effective immediately, the addition, amendment and/or 32 repeal of any rule or regulation necessary for the implementation of 33 this act on its effective date are authorized to be made and completed 34 on or before such effective date.