C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-103, subsec. 144-101-II-103.07

Current through 2024-51, December 18, 2024

Subsection 144-101-II-103.07 - REIMBURSEMENT

103.07-1General Reimbursement

RHCs are reimbursed in accordance with the requirements of section 702 of the Benefits Improvement and Protection Act (BIPA) of 2000, including requirements for a Prospective Payment System.

Reimbursement is generally limited to one core service visit, and/or one ambulatory service visit per day. Reimbursement for a second core visit is also covered if the member has both an encounter with a physician, physician assistant, nurse practitioner or visiting nurse, and in addition to that encounter, is seen by a licensed clinical psychologist, clinical social worker, clinical professional counselor, clinical nurse specialist, or a registered nurse certified in the specialized field of mental health, on the same day. An additional visit of any kind will only be reimbursed for unforeseen circumstances as documented in the member's record.

Additional clinic visits required in the member's treatment plan that do not qualify as clinic visits for reimbursement purposes, such as a visit for venipuncture only, are non-billable and are included in the RHC's cost based reimbursement.

103.07-2PPS Reimbursement Methodology

A.Initial PPS Rates and Annual Adjustments

Effective January 1, 2020, Rural Health Clinics can choose to be reimbursed on the basis of 100% of the average of their reasonable costs of providing MaineCare-covered services during:

(a) calendar years 1999 and 2000 with historical Medicare Economic Index (MEI) adjustments; or

(b) calendar years 2016 and 2017. The resulting average will be adjusted to take into account any increase or decrease in the approved scope of services furnished during the provider's fiscal year 2001 (for choice (a)), or 2018 (for choice (b)), respectively (calculating the amount of payment on a per visit basis).*

At the start of each subsequent year, beginning in CY 2002 (for choice (a)) or CY 2021 (for choice (b)), each RHC is entitled to the payment amount (on a per visit basis) to which the clinic was entitled under the Act in the previous fiscal year, inflated by the percentage increase in the MEI for primary care services, and adjusted to take into account any increase or decrease for a MaineCare approved "change in scope of services."*

* The Department submitted to CMS and anticipates approval of a State Plan Amendment (SPA) related to these provisions.

Newly qualified RHCs after state fiscal year 2017 will have initial payments (calculated on a per visit basis) established either by reference to payments to other RHCs in the same or adjacent areas with similar caseload, or in the absence of such other RHCs, through cost reporting methods. Cost reports must accurately reflect the costs of the individual RHC (i.e. may not be a consolidated report of multiple sites or organizations that is not able to distinguish RHC costs.) For each fiscal year following the initial year, payment shall bead justed for MEI and approved "change in scope of services." This applies to each new RHC site or location with a separate National Provider Identifier that is opening for the first time, regardless of affiliation to an existing organization, and regardless of previous service delivery.

B."Change in Scope of Services" Requests and Adjustments

A "change in the scope of services" refers to a change in the overall picture of a RHC's services through a change in the type, intensity, duration and/or amount of services.

The following examples are offered as guidance to RHCs to facilitate understanding of the types of changes that may be recognized as a "change in scope of services." These examples should not be interpreted as a definitive nor comprehensive delineation of the definition of "change of scope of services."

1. The addition of a new covered service or deletion of an existing covered service that is present in the existing PPS rate. Covered services are those which meet the definition of RHC services as provided in section 1905(a)(2)(B) of the Social Security Act;

2. The addition of a new professional staff (i.e. employed or contracted) who is licensed to perform a covered service that no current professional staff is licensed to perform;

3. A change in the intensity of a service that fundamentally alters the service delivery model and increases or decreases the quantity of labor and materials consumed by an individual during an average encounter. This change may be attributed to changes in the types of patients served.

An increase or decrease in "scope of services" does not necessarily result from any of the following (although some of these changes may occur in conjunction with a "change in scope of services"):

1. A change in the cost of providing an existing service;

2. A change of ownership;

3. A change in status between free-standing and provider-based;

4. The expansion of an existing service to a new population;

5. The expansion of the RHC to a new site which provides the same services;

6. The addition or reduction of staff members to or from an existing service;

7. A change in office hours; or,

8. An increase or decrease in the number of encounters.

It is the RHC's responsibility to notify the Department of any "change in the scope of services" and provide proper documentation to support the rate change request. The RHC must submit either at least six (6) months of actual cost data for changes that have already taken place, or twelve (12) months of projected costs for anticipated changes.

When an RHC submits projected costs for an anticipated change in the scope of services that amounts to a PPS rate change that is greater than or equal to five percent (5%), the Department may request data from the RHC when at least six (6) months of actual data becomes available for a rate review and adjustment as determined by the Department. The RHC must also submit a narrative describing the change. Requests for a rate adjustment based on a prior change must be received no later than one hundred and fifty (150) days after the RHC's fiscal year end in which the "change in scope of services" occurred. The Department will respond with a decision to a rate adjustment request within sixty (60) days of receiving a completed application. An application is considered complete when the Department confirms that it has received all the information needed to process the application.

Adjustments to the PPS rate for the increase or decrease in scope of services will be reflected in the PPS rate beginning with services provided the first day of the month immediately following either the date the Department approves the "change in scope of services" adjustment or the date an anticipated change will begin, whichever is later.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-103, subsec. 144-101-II-103.07