Kan. Admin. Regs. § 30-5-82a

Current through Register Vol. 43, No. 24, June 13, 2024

Section 30-5-82a - Reimbursement for rural health clinic services

Reimbursement for rural health clinic services and other ambulatory services covered by the Kansas medical assistance program shall be at reasonable cost pursuant to 42 CFR 447.371, effective September 30, 1986; 42 CFR Part 413, revised as of October 1, 1997; Section 4205 of the balanced budget act of 1997; and the provisions discussed in this regulation.

(a) Reimbursement method. An interim rate per visit shall be paid to each rural health clinic, subject to a fiscal year-end retroactive cost settlement.

(b) Interim reimbursement rate per visit.

(1) Rate for independent rural health clinic. Each clinic shall be paid by the agency the all-inclusive reasonable cost rate per visit determined by the medicare carrier.

(A) Initial rate at enrollment. The medicaid payment rate shall be the current medicare rate.

(B) Rate changes. The interim payment rate of an independent rural health clinic shall be changed by the agency each time a rate change notification for that clinic is received from the medicare carrier.

(2) Rate for provider-based rural health clinic.

(A) Initial rate at enrollment. An estimated payment rate per visit that is no more than the medicare payment limit shall be set by the agency.

(B) Rate changes. After cost settlement of a provider-based clinic, the interim payment rate shall be changed by the agency based on paragraph (d)(2)(B) below.

(c) Visit. A "visit" means a face-to-face encounter between a clinic patient and a health care professional as defined in K.A.R. 30-5-82. Encounters with more than one health professional or multiple encounters with the same health professional that take place on the same day shall constitute a single visit except when, after the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment.

(d) Retroactive cost settlement. The allowable medicaid cost shall be determined by the agency, and this cost shall be compared by the agency to the total payments to determine the amount overpaid or underpaid for each cost-reporting period. "Total payments" shall include interim reimbursements, health connect Kansas case management payments, third party liability, and any other payment for covered services.

(1) Cost settlement for independent rural health clinic.

(A) Cost report. The audited medicare cost report of the independent rural health clinic received from the medicare carrier shall be used by the agency.

(B) Allowable Kansas medical assistance program cost. The allowable medicaid cost of an independent rural health clinic shall be obtained by applying the audited medicare reimbursement rate per visit to medicaid paid claims data. For independent rural health clinic providers with multiple locations, aggregate medicaid paid claims data for all clinics shall be used.

(2) Cost settlement for provider-based rural health clinic.

(A) Cost report. The audited medicare cost report of the health care organization of which the rural health clinic is a part shall be used by the agency. This cost report is provided by the medicare intermediary.

(B) Allowable Kansas medical assistance program cost. Pursuant to 42 CFR 413.9(a) and Section 4205 of the balanced budget act of 1997, the allowable medicaid cost shall be the lowest of the following three amounts:

(i) Cost computed by using the cost report;

(ii) cost computed by applying medicare maximum rate; or

(iii) billed charges.

(e) Fiscal and statistical records and audits. The requirements in K.A.R. 30-5-118a(d) shall apply.

(f) This regulation shall take effect on and after January 1, 1999.

Kan. Admin. Regs. § 30-5-82a

Authorized by and implementing K.S.A. 1997 Supp. 39-708c; effective May 1, 1981; amended July 1, 1994; amended Jan. 1, 1999.