Comprehensive Outpatient Program Services (COPS) Level I Description

Level I Comprehensive Outpatient Program Services (Level I COPS) is a program which enables a provider of licensed mental health outpatient services to be eligible to receive supplemental medical assistance reimbursement (Level I COPS Medicaid revenue – or simply Level I COPS) in exchange for the provision of enhanced outpatient services in accordance with 14 New York Codes, Rules and Regulations (NYCRR) Part 592 (the Level I COPS regulations). The local governmental unit (LGU) is responsible for ensuring the Level I COPS providers under its jurisdiction provide the enhanced outpatient services consistent with Level I COPS regulations, including a written agreement with designated providers, as required by 14 NYCRR Part 592.6 and 592.7.

Receipt of Level I COPS revenue is contingent upon either (a) the maintenance of a Tier I or Tier II designation (on the applicable outpatient program’s operating certificate, as issued by Office of Mental Health), or, in the event that a program has a Tier III designation, (b) submission of an acceptable plan of corrective action. During any period of time that a provider may be in Tier III status, prior to submission of an acceptable plan of corrective action, the Level I COPS supplement will be removed from their reimbursement.  This is a permanent reduction to the provider’s reimbursement.

Level I COPS is paid to providers through the Medicaid payment system. Specifically, by Computer Sciences Corporation (CSC) – the State’s Medicaid paying agent, through the Medicaid Management Information System (MMIS), by way of a provider and program-specific Level I COPS Medicaid rate add-on (the Level I COPS rate).

Historical Context

The Level I COPS program was established for programs designated as eligible by the appropriate LGU in 1991 for Article 31 Clinic, Continuing Day Treatment (CDT) and Day Treatment programs, and in 1992 for Article 28 general hospitals. Upon inception of the Level I COPS program, there were separate Level I COPS rates for each outpatient program for each provider. These rates were combined into one Level I COPS rate for each provider two years later. In 1995, additional Level I COPS base supplement funds were added to the program. Periodic Cost of Living Adjustment (COLA) increases have also been added to the Level I COPS program. During 2001, the Intensive Psychiatric Rehabilitation Treatment (IPRT) and Partial Hospitalization (PH) programs became eligible for Level I COPS reimbursement. In 2003, the State funded shared staff who were working under local auspice and were repatriated back to the state psychiatric centers and additional Level I COPS base supplement funding for these positions was added to the Level I COPS program. In 2003, Office of Mental Health (OMH) reverted back to separate Level I COPS rates for each program for each provider in anticipation of implementation of the Personalized Recovery Oriented Services (PROS) Program. Also, in 2003, 2004, 2005, and 2008, there was further expansion of the Level I COPS program, through the inclusion of additional eligible funds.

Cops Rates

The specifics of each provider’s Level I COPS program are contained in their Level I COPS rate sheet, which is maintained by the Office of Mental Health Comprehensive Outpatient Program Services/Community Support Program (OMH COPS/ Community Support Program (CSP)) Rate Setting Unit. When a provider’s Level I COPS rate changes, a rate sheet which details the changes and elements necessary for rate calculation is sent to the provider, accompanied by a letter explaining the change(s).
Providers may contact the COPS/CSP Rate Setting Unit for all questions pertaining to the rate sheet at any time.

The Level I COPS rate is calculated by OMH, and is equal to the total Level I COPS funding as determined by the LGU (see Part 592.8(c)) for that particular outpatient program, divided by the product of (1) the three year average of paid Medicaid claims, from the three most recent fiscal years for which data is available, or an approved appeal amount (Data Source: MMIS), (2) 90.9% (the Level I COPS constant – a vacancy factor to increase the rate), and (3) the provider and program-specific Medicare/Medicaid crossover percentage. The specifics of each provider’s rate calculation are contained in their rate sheet. Level I COPS rates are recalculated for each provider annually based on an updated three year average of Medicaid paid claims.
Program specific exceptions are:

• CDT-Effective April 1, 2009 Level I COPS rates attached to Continuing Day Treatment (CDT) programs were recalculated utilizing actual paid claims for service dates April 1, 2009 through March 31, 2011 to reflect the half-day/full day visit approach methodology. This adjustment will be in effect until such time as the three year average reflects actual billing, thus supporting the actual cost of the program.
  
  
• Clinic- Effective July 1, 2008 the Level I COPS clinic rates were rebased for the final time using updated paid Medicaid visits for the higher of, a) the number of paid visits from calendar year 2007, or b) the average number of paid visits provided in the calendar years 2005 – 2007, as required by 14 NYCRR part 592. These visits shall include all visits reimbursed by Medicaid, visits partially reimbursed by Medicare, and those for which payment has been made or approved by a Medicaid managed care organization, which have no corresponding COPS-Only paid visit. Changes made to any of the COPS calculations components would also warrant a change to the specific provider(s) COPS rate.

Level I COPS Medicaid rates are subject to a ‘cap’ or maximum amount, which is adjusted periodically. The cap effective January 1, 2009 is $300.00.

The crossover percentage in the Level I COPS rate increases the rate to mitigate the negative fiscal dynamic of Medicare upon Level I COPS revenue. Only providers who operate outpatient mental health programs which provide services to Medicare/Medicaid dually eligible clients, and have instances where the Medicare approved amount is greater than base Medicaid, are eligible to have this percentage incorporated into their rate calculation. The crossover percentage is used because  providers could not otherwise receive a complete Level I COPS payment on each paid claim due to the fiscal impact of Medicare.

The crossover percentage is calculated by dividing the average amount of Level I COPS paid on each Level I COPS paid claim for services provided during a particular service period, by the Level I COPS rate in effect for that service period. This percentage is intended to represent the percentage of Level I COPS paid on all of Level I COPS paid claims, not just the percentage paid on crossover Level I COPS paid claims; please refer to the Medicare/Medicaid crossover methodology that is detailed later in this document.

This Level I COPS rate is then added to the Medicaid rates already in effect for that provider, for that program. However, for Article 28 general hospitals, Level I COPS is not added to the clinic collateral or group collateral rate codes, or the CDT collateral or group collateral rate codes.

Providers are responsible for accounting for the amount of Level I COPS they receive. In order to properly account for Level I COPS, it is essential providers become familiar with the Medicare/Medicaid crossover payment methodology. In most cases, Level I COPS per paid claim is equal to the Level I COPS rate. However, for paid claims that involve Medicare, the determination of how much Level I COPS is received per paid claim depends upon the extent of the Medicare approved and paid components. Please refer to the crossover methodology explained later in this document.

An LGU, or a provider with the support from the LGU, may appeal the Level I COPS Medicaid rate within sixty (60) days of receipt of the rate notification.

Providers should also be aware that when Level I COPS rates are recalculated retroactively, due to data and timing factors, there will be an effect on their Medicaid checks. When the new rate is lower than the previous rate, MMIS will recoup the difference between the two rates for all paid services, retroactive to the effective date of the rate change. When the new rate is higher than the previous rate, MMIS will send a check for the difference between the two rates for all paid services, retroactive to the effective date of the rate change. These actions by MMIS are taken only due to the change in rate and are unrelated to the Level I COPS revenue reconciliation outlined later in this document.

Level I COPS Threshold

The amount of Level I COPS a provider can retain in any local fiscal year, for a particular Level I COPS program, is equal to that program’s Level I COPS threshold. The Level I COPS threshold is a provider and program-specific amount, and is equal to no more than the full annual amount of the Level I COPS base supplement funding for that program, plus 10%. It is important to note any Level I COPS funding added to the Level I COPS rates which was originally 500 COLA, shared staff, or Level II COPS (a/k/a: Non-COPS), may not be eligible for the additional 10%. Details concerning the threshold, are contained in the Level I COPS rate sheet, which is distributed to the providers any time a change to their COPS funding occurs.

All Clinic services rendered on or after July 1, 2008 will no longer be subject to the Level I COPS Reconciliation process. The final Clinic Thresholds have been calculated for Upstate and Long Island providers for the period January 1, 2008 – June 30, 2008; and for New York City providers July 1, 2007 – June 30, 2008. All other programs are subject to the Level I COPS Reconciliation process.

Level I COPS Revenue Reconciliation

OMH maintains a Medicaid payment database that reflects payments made to providers consistent with the information contained in the Medicaid remittance statements which accompany each Medicaid check. Providers must keep track of Level I COPS revenue receipts. Any Level I COPS revenue received in excess of the Level I COPS threshold must be kept in a reserve account for future recovery by the OMH.

Level I COPS received in a local fiscal year in excess of that year’s Level I COPS threshold will be recouped by the State through MMIS (see Part 592.4(f)). A Level I COPS payment report will be sent to each provider detailing the amount of Level I COPS that OMH has determined the provider received, as compared to their threshold for the program for the fiscal year, during the reconciliation process. Providers will have an opportunity to verify the data used to calculate the recovery amount by the OMH before implementation of the recovery by MMIS. Included in any notice of recovery of overpayment will be a description of the recovery process.

Medicare/Medicaid Crossover Payment Methodology

In order to determine the individual Medicaid components (base Medicaid, Level I COPS, CSP and/or Level II Level I COPS) of a Medicaid payment made on a Medicare/Medicaid Crossover (crossover) paid claim you will need to know the following information:

• the crossover logic – Medicaid payment on a crossover paid claim is limited to the difference between either the Medicare approved amount and Medicare paid amount, or the Medicaid rate and Medicare paid amount, whichever is greater;
• the Medicare approved amount associated with the particular rate code the crossover logic is being applied against – please be aware that Medicare approved, and Medicare allowed, are synonymous;
• the Medicare paid amount for the particular rate code in question;
• the base Medicaid rate/fee – all Article 28 providers, and some D&TC providers, have base Medicaid rates for clinic, CDT, and day treatment; all Article 31 providers, and some Diagnostic & Treatment Center (D&TC) providers, have base Medicaid fees for clinic, CDT, and day treatment; all providers have base Medicaid fees for partial hospitalization (PH) and intensive psychiatric rehabilitation treatment programs (IPRT) – although for the purpose of this explanation, base rates and base fees will both be referred to as base Medicaid rates (see Part 588.13);
• the Level I COPS rate, if applicable;
• the CSP rate, if applicable;
• the Level II Level I COPS fee supplement, if applicable;
• the total Medicaid rate for a particular outpatient program; and
• the total amount paid (Medicare plus Medicaid),

Then apply the following logic to calculate the component parts of your Medicaid payment:

For providers who receive Level I COPS and CSP on the same rate code

• Determine the Medicaid payment by subtracting Medicare paid from the total amount paid.
• Determine the base Medicaid component:
• If the base Medicaid rate is greater than or equal to Medicare approved, then the base Medicaid component is equal to the difference between the base Medicaid rate, and Medicare paid.
• In all other cases, the base Medicaid component is equal to the difference between Medicare approved, and Medicare paid.
• Determine the base Medicaid plus Level I COPS component:
• If the sum of the base Medicaid rate and the Level I COPS rate is greater than or equal to Medicare approved, then the base Medicaid plus Level I COPS component is equal to the difference between the sum of the base Medicaid rate and the Level I COPS rate, and Medicare paid.
• In all other cases, the base Medicaid plus Level I COPS component is equal to the difference between Medicare approved and Medicare paid.
• Determine the Level I COPS component by subtracting the base Medicaid component from the base Medicaid plus Level I COPS component.
• Determine the CSP component by subtracting the base Medicaid plus Level I COPS component from the Medicaid payment.

For providers who receive CSP and Level II Level I COPS on the same rate code, apply the same logic as above, substituting Level II Level I COPS for Level I COPS.

For providers who receive just Level I COPS, CSP, or Level II Level I COPS on a particular rate code apply the same logic as above, assuming all unused rate components are equal to $0.

Please note:
In no instance can the Level I COPS, CSP, or Level II COPS payment credited through the application of this logic be less than $0.

Level I COPS Reporting & Claiming

Article 31 and D&TC providers should account for Level I COPS on the Level I COPS cash basis. This is the accounting basis the OMH employs for the purpose of determining how much Level I COPS Article 31 and D&TC providers are paid in a particular local fiscal year. According to this accounting basis, Level I COPS is considered paid consistent with the date on the Medicaid check, and assumes that any retroactive Level I COPS rate changes are repatriated to their original payment date by the provider.

For example:

• on January 1, 2011, the Level I COPS clinic rate is $20;
• on January 1, 2011, the clinic provides a clinic service to a Medicaid-eligible person;
• in March 2011 the clinic receives a check from Medicaid – dated March 1, 2011 – that contains $20 of Level I COPS for this January 1, 2011, service (this is the first-instance payment);
• in June 2011, the clinic’s Level I COPS rate is changed retroactive to January 1, 2011, to $30;
• in June 2011, MMIS will automatically pay the clinic the $10 increment associated with this rate change;
• The OMH’s Medicaid data base repatriates the $10 such that the Level I COPS payment made for this service on March 1, 2011, is $30 (the data base does not consider the $10 payment made in June 2011, but in March 2011).

For Upstate and Long Island Article 31 and D&TC providers, the Level I COPS payment report will detail the provider’s calendar year Level I COPS threshold, and corresponding Level I COPS paid amount.

For New York City (NYC) Article 31 and D&TC providers, the Level I COPS payment report will detail the local fiscal year – July through June – Level I COPS threshold, and corresponding Level I COPS paid amount.

Article 28 general hospitals should account for Level I COPS on the Level I COPS accrual basis. This is the accounting basis the OMH employs for the purpose of determining how much Level I COPS Article 28 general hospitals accrue in a particular local fiscal year, and, when this amount is compared to the Level I COPS threshold, how much Level I COPS to recover through MMIS. According to this accounting basis, Level I COPS is considered paid consistent with the description provided above for Article 31 and D&TC providers. However, for the purpose of estimating Level I COPS accrued in a local fiscal year, OMH employs the following algorithm:

• for Upstate and Long Island Article 28 general hospitals, Level I COPS accrued in 200x is equal to
  • Level I COPS paid during the period January 1, 200x, through March 31, 200x+1, for services provided during 200x, plus
  • Level I COPS paid during the period April 1, 200x, through March 31, 200x+1, for services provided prior to 200x;
• for NYC Article 28 general hospitals, Level I COPS accrued in Local Fiscal Year (LFY) 200x - 200x+1 (i.e., July 1, 2002, through June 30, 2003) is equal to
  • Level I COPS paid during the period July 1, 200x, through September 30, 200x+1, for services provided during LFY 200x - 200x+1, plus
  • Level I COPS paid during the period October 1, 200x, through September 30, 200x+1, for services provided prior to LFY 200x – 200x+1.

For Upstate and Long Island Article 28 general hospitals, the Level I COPS payment report will detail the calendar year Level I COPS threshold, and corresponding Level I COPS accrued amount.

For NYC Article 28 general hospitals, the Level I COPS payment report will detail your LFY Level I COPS threshold, and corresponding Level I COPS accrued amount.

For all providers, if an overpayment is detailed it will be recovered by the State through MMIS. If an underpayment is detailed, no action is taken.

Please see Appendix DD of the Consolidated Fiscal Reports (CFR) manuals for budgeting and claiming guidelines.

Resources:

• Financial Guidance and Resources - References for COPS, CSP and DSH Descriptions
• Part 587 Regulations Operation of Outpatient Programs
• Part 588 Regulations Medical Assistance for Outpatient Programs
• Part 592 Regulations Comprehensive Outpatient Programs
• Clinic Restructuring Implementation Plan

Appendix DD of the CBR manual (contains Level I COPS, Level II COPS and CSP fiscal reporting) is available online.

Comments or questions about the information on this page can be directed to the Community Budget & Financial Management (CBFM) Group.