10 Colo. Code Regs. § 2505-10-8.740
Current through Register Vol. 47, No. 24, December 25, 2024
Section 10 CCR 2505-10-8.740 - RURAL HEALTH CLINICS8.740.1DEFINITIONSRural Health Clinic (RHC) means a clinic or center that:
1. Has been certified as a Rural Health Clinic under Medicare.2. Is located in a rural area, which is an area that is not delineated as an urbanized area by the Bureau of the Census.3. Has been designated by the Secretary of Health and Human Services as a Health Professional Shortage Area (HPSA) through the Colorado Department of Public Health and Environment.4. Is not a rehabilitation facility or a facility primarily for the care and treatment of mental diseases. Visit means a face-to-face encounter, or an interactive audio (including but not limited to telephone and relay calls), interactive video (including but not limited to interactive audiovisual modalities), or interactive data communication (including but not limited to live chat and excluding text messaging, electronic mail, and facsimile transmission) encounter in accordance with Section 8.095, between a clinic client and a health professional providing the services set forth in 8.740.4. Any health benefits provided through interactive audio, interactive video, or interactive data communication must meet the same standard of care as in-person care.
8.740.2REQUIREMENTS FOR PARTICIPATION8.740.2.A. A Rural Health Clinic shall be certified under Medicare.8.740.2.B. A Rural Health Clinic providing laboratory services shall be certified as a clinical laboratory in accordance with 10 C.C.R 2505-10, Section 8.660.8.740.3CLIENT CARE POLICIES8.740.3.A. The Rural Health Clinic's health care services shall be furnished in accordance with written policies that are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member of the group shall not be a member of the Rural Health Clinic staff.8.740.3.B. The policies shall include: 1. A description of the services the Rural Health Clinic furnishes directly and those furnished through agreement or arrangement. See section 8.740.4.A.4.2. Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or client referral, the maintenance of health care records and procedures for the periodic review and evaluation of the services furnished by the Rural Health Clinic.3. Rules for the storage, handling and administration of drugs and biologicals.8.740.4SERVICES8.740.4.A. The following services may be provided by a certified Rural Health Clinic: 1. General services a. Outpatient primary care services that are furnished by a physician assistant, clinical psychologist, clinical social worker, nurse practitioner, nurse midwife, licensed professional counselor, licensed marriage and family therapist, or licensed addiction counselor as defined in their respective practice acts. b. Part-time or intermittent visiting nurse care.c. Services and medical supplies, other than pharmaceuticals, that are furnished as a result of professional services provided under 8.740.4.A.1.a and b.2. Laboratory services. Rural Health Clinics furnish basic laboratory services essential to the immediate diagnosis and treatment of the client.3. Emergency services. Rural Health Clinics furnish medical emergency procedures as a first response to common life-threatening injuries and acute illness and must have available the drugs and biologicals commonly used in life saving procedures.4. Services provided through agreements or arrangements. The Rural Health Clinic has agreements or arrangements with one or more providers or suppliers participating under Medicare or Medicaid to furnish other services to clients, including inpatient hospital care; physician services (whether furnished in the hospital, the office, the client's home, a skilled nursing facility, or elsewhere) and additional and specialized diagnostic and laboratory services that are not available at the Rural Health Clinic.8.740.5PHYSICIAN RESPONSIBILITIES8.740.5.A. A physician shall provide medical supervision and guidance for physician assistants and nurse practitioners, prepare medical orders, and periodically review the services furnished by the clinic. A physician shall be present at the clinic for sufficient periods of time to fulfill these responsibilities and must be available at all times by direct means of communications for advice and assistance on client referrals and medical emergencies. A clinic operated by a nurse practitioner or physician assistant may satisfy these requirements through agreements with one or more physicians.8.740.6ALLOWABLE COSTS8.740.6.A. The following types and items of cost shall be included in allowable costs to the extent that they are covered and reasonable: 1. Compensation for the services of a physician who owns, is employed by, or furnishes services under contract to a Rural Health Clinic.2. Compensation for the duties that a supervising physician is required to perform.3. Costs of services and supplies incident to the services of a physician, physician assistant, clinical psychologist, clinical social worker, nurse practitioner, nurse-midwife, licensed professional counselor, licensed marriage and family therapist, or licensed addiction counselor.4. Overhead costs, including clinic or center administration, costs applicable to use and maintenance of the entity and depreciation costs.5. Costs of services purchased by the Rural Health Clinic.8.740.7REIMBURSEMENT8.740.7.A. The Department shall reimburse Rural Health Clinics a per visit encounter rate. Encounters with more than one health professional, and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except when the client, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment. An RHC may be reimbursed for up to two separate encounters with the same client occurring in the same day and at the same location, so long as the two encounters submitted for reimbursement are a physical health and a behavioral health service.8.740.7.B. Rural Health Clinic rates are updated annually on January 1st. The encounter rate shall be the higher of:
1. The Prospective Payment System (PPS), as defined by Section 702 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) included in the Consolidated Appropriations Act of 2000, Public Law 106-554, BIPA is incorporated herein by reference. No amendments or later editions are incorporated. The Acute Care Benefits Section Manager at the Colorado Department of Health Care Policy and Financing may be contacted at 1570 Grant Street, Denver, Colorado 80203, for a copy of BIPA, or the materials may be examined at any publications depository library.2. The Alternative Payment Methodology (APM) rate. a. The APM rate for hospital based Rural Health Clinics shall be based on actual costs. i. The interim rate for Rural Health Clinics shall be the higher of the current year PPS rate and the most recent audited and finalized cost per visit from the Medicare cost report.ii. After a Rural Health Clinic's Medicare cost report has been audited and finalized, the Department shall perform a reconciliation for the services provided by the Rural Health Clinic during the year the cost report covers. If the Department's interim rate was below the finalized rate, a one-time payment will be made to the Rural Health Clinic. If the Department's interim rate was above the finalized rate and the PPS rate, the Department will recoup the difference from the RHC.b. The APM rate for freestanding Rural Health Clinics is the Medicare upper payment limit for Rural Health Clinics.8.740.7.C. New RHCs shall be reimbursed an interim per visit encounter rate, which shall be calculated as follows:1. For new freestanding RHCs, the interim rate will be the average of other freestanding RHC's APM rates in the new RHC's Regional Accountable Entity (RAE).2. For new hospital-based RHCs, the interim rate will be calculated based on the following options in the following order: a. The per visit encounter rate established by a Medicare rate letter; or b. A sister clinic's per visit encounter rate. A hospital-based RHC's interim rate will be updated if the RHC provides an updated Medicare rate letter. The new rate will be effective the following January 1st.
8.740.7.D. PPS rates for new RHCs shall be calculated as follows: 1. For new freestanding RHCs, the PPS rate shall be calculated based on the average of other freestanding RHC's PPS rates in the new RHC's RAE.2. For new hospital-based RHCs, the PPS rate shall be calculated based on an average of two year's audited cost and visit data from the RHC's Medicare cost report.8.740.7.E. The Department will reimburse Long-Acting Reversible Contraception (LARC) and Non-surgical Transcervical Permanent Female Contraceptive Devices separate from the Rural Health Clinic per visit encounter rate. Reimbursement will be the lower of: 1. 340B acquisition costs;3. Fee schedule as determined by the Department.8.740.7.F. PPS Change in Scope 1. If an RHC changes its scope of service after the year in which its base PPS rate was determined, the Department will adjust the RHC's PPS rate in accordance with section 1902(bb) of the Social Security Act.a. An RHC must apply to the Department for an adjustment to its PPS rate whenever there is a documented change in the scope of service of the RHC. The documented change in the scope of service of the RHC must meet all of the following conditions: i. The increase or decrease in cost is attributable to an increase or decrease in the scope of service that is a covered benefit, as described in Section 1905(a)(2)(C) of the Social Security Act and is furnished by the RHC.ii. The cost is allowable under Medicare reasonable cost principles set forth in 42 CFR Part 413.5 iii. The change in scope of service is a change in the type, intensity, duration, or amount of services, or any combination thereof.iv. The net change in the RHC's per-visit encounter rate equals or exceeds 3% for the affected RHC. For RHCs that file consolidated cost reports for multiple sites in order to establish the initial PPS rate, the 3% threshold will be applied to the average per-visit encounter rate of all sites for the purposes of calculating the cost associated with the scope-of-service change.v. The change in scope must have existed for at least a full six (6) months.b. A change in the cost of a service is not considered in and of itself a change in scope of service. The change in cost must meet the conditions set forth in Section 8.740.7.F.1.a . and the change in scope of service must include at least one of the following to prompt a scope-of-service rate adjustment. If the change in scope of service does not include at least one of the following, the change in the cost of services will not prompt a scope-of-service rate adjustment. i. The addition of a new service not incorporated in the baseline PPS rate, or deletion of a service incorporated in the baseline PPS rate;ii. The addition or deletion of a covered Medicaid service under the State Plan;iii. Changes necessary to maintain compliance with amended state or federal regulations or regulatory requirements;iv. Changes in service due to a change in applicable technology and/or medical practices utilized by the RHC;v. Changes resulting from the changes in types of patients served, including, but not limited to, populations with HIV/AIDS, populations with other chronic diseases, or homeless, elderly, migrant, or other special populations that require more intensive and frequent care; vi. Changes resulting from a change in the provider mix, including, but not limited to: a. A transition from mid-level providers (e.g. nurse practitioners) to physicians with a corresponding change in the services provided by the RHC;b. The addition or removal of specialty providers (e.g. pediatric, geriatric, or obstetric specialists) with a corresponding change in the services provided by the RHC (e.g. delivery services);c. Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and/or residents; or,d. Changes in the operating costs attributable to capital expenditures (including new, expanded, or renovated service facilities), regulatory compliance measures, or changes in technology or medical practices at the RHC, provided that those expenditures result in a change in the services provided by the RHC.c. The following are examples of items that do not prompt a scope-of-service rate adjustment: i. An increase or decrease in the cost of supplies or existing services;ii. An increase or decrease in the number of encounters;iii. Changes in office hours or location not directly related to a change in scope of service;iv. Changes in equipment or supplies not directly related to a change in scope of service;v. Expansion or remodel not directly related to a change in scope of service;vi. The addition of a new site, or removal of an existing site, that offers the same Medicaid-covered services;vii. The addition or removal of administrative staff;viii. The addition or removal of staff members to or from an existing service;ix. Changes in salaries and benefits not directly related to a change in scope of service.x. Change in patient type and volume without changes in type, duration, or intensity of services;xi. Capital expenditures for losses covered by insurance; or,xii. A change in ownership.d. An RHC must apply to the Department by written notice within one hundred and fifty (150) days of the end of the RHC's fiscal year in which the change in scope of service occurred. Only one scope-of-service rate adjustment will be calculated per year. However, more than one type of change in scope of service may be included in a single application.e. Should the scope-of-service rate application for one year fail to reach the threshold described in Section 8.740.7.F.1.a .iv, the RHC may combine that year's change in scope of service with a valid change in scope of service from the next year or the year after. For example, if a valid change in scope of service that occurred in FY 2021 fails to reach the threshold needed for the rate adjustment, and the RHC implements another valid change in scope of service during FY 2022, the RHC may submit a scope-of-service rate adjustment application that captures both of those changes. An RHC may only combine changes in scope of service that occur within a three-year time frame and must submit an application for a scope-of-service rate adjustment as soon as possible after each change has been implemented. Once a change in scope of service has resulted in a successful scope-of-service rate adjustment either individually or in combination with another change in scope of service, that change may no longer be used in an application for another scope of service rate adjustment.f. The documentation for the scope-of-service rate adjustment is the responsibility of the RHC. Any RHC requesting a scope-of-service rate adjustment must submit the following to the Department: i. The Department's application form for a scope-of-service rate adjustment, which includes; a. The provider number(s) that is/are affected by the change(s) in scope of service;b. A date on which the change(s) in scope of service was/were implemented;c. A brief narrative description of each change in scope of service, including how services were provided both before and after the change;d. Detailed documentation such as cost reports that substantiate the change in total costs, total health care costs, and total visits associated with the change(s) in scope; ande. An attestation statement that certifies the accuracy, truth, and completeness of the information in the application signed by an officer or administrator of the RHC;ii. Any additional documentation requested by the Department. If the Department requests additional documentation to calculate the rate for the change(s) in scope of service, the RHC must provide the additional documentation within thirty (30) days. If the RHC does not submit the additional documentation within the specified timeframe, the Department, at its discretion, may postpone the implementation of the scope-of-service rate adjustment. g. The reimbursement rate for a scope-of-service change applied for January 1, 2022 or afterwards will be calculated as follows: i. The Department will first verify the total costs, the total covered health care costs, and the total number of visits before and after the change in scope of service. The Department will also calculate the Adjustment Factor (AF = covered health care costs/total cost of RHC services) associated with the change in scope of service of the RHC. If the AF is 80% or greater, the Department will accept the total costs as filed by the RHC. If the AF is less than 80%, the Department will reduce the costs other than covered health care costs (thus reducing the total costs filed by the RHC) until the AF calculation reaches 80%. These revised total costs will then be the costs used in the scope-of-service rate adjustment calculation.ii. The Department will then use the appropriate costs and visits data to calculate the adjusted PPS rate. The adjusted PPS rate will be the average of the costs/visits rate before and after the change in scope of service, weighted by visits.iii. The Department will calculate the difference between the current PPS rate and the adjusted PPS rate. The "current PPS rate" means the PPS rate in effect on the last day of the reporting period during which the most recent scope-of-service change occurred. iv. The Department will check that the adjusted PPS rate meets the 3% threshold above. If it does not meet the 3% threshold, no scope-of-service rate adjustment will be implemented. v. Once the Department has determined that the Adjusted PPS rate has met the 3% threshold, the adjusted PPS rate will then be increased by the Medicare Economic Index (MEI) to become the new PPS rate.h. The Department will review the submitted documentation and will notify the RHC in writing within one hundred twenty (120) days from the date the Department received the application as to whether a PPS rate change will be implemented. Included with the notification letter will be a rate-setting statement sheet, if applicable. The new PPS rate will take effect the following January 1st. j. An RHC may request a written informal reconsideration of the Department's decision of the PPS rate change regarding a scope-of-service rate adjustment within thirty (30) days of the date of the Department's notification letter. The informal reconsideration must be mailed to the Department of Health Care Policy and Financing, 1570 Grant St, Denver, CO 80203. To request an informal reconsideration of the decision, an RHC must file a written request that identifies specific items of disagreement with the Department, reasons for the disagreement, and a new rate calculation. The RHC should also include any documentation that supports its positions. A provider dissatisfied with the Department's decision after the informal reconsideration may appeal that decision through the Office of Administrative Courts according to the procedures set forth in 10 CCR 2505-10 Section 8.050.3, PROVIDER APPEALS.