Mo. Code Regs. tit. 9 § 10-31.040

Current through Register Vol. 49, No. 21, November 1, 2024.

Section 9 CSR 10-31.040 - Community Mental Health Center Clinic UPL

PURPOSE: This rule establishes the formula to determine supplemental payments under Medicaid subject to the clinic upper payment limit to Community Mental Health Center Clinics (CMHC).

(1) Definitions. The terms used in this rule shall mean

(A) Medicare rate is the rate established in the 2010 Resource Based Relative Value Scale (RVRVS) table plus the Health Professional Shortage Area (HPSA) add on payment; and

(B) Current Medicaid rate is the rate on file with the MO HealthNet Division at the beginning of the state fiscal year.

(2) Supplemental Payment to Community Mental Health Centers. The Department of Mental Health (DMH) contracts with privately owned and operated Community Mental Health Centers (CMHCs), which act as administrative entities of DMH. The CMHCs are designated as entry and exit points for DMH services and are required to provide a comprehensive array of services to any DMH patients in their designated service areas who seek care.

(3) To recognize the CMHCs' higher costs of doing business and their role as safety net providers, each Missouri CMHC will be paid an annual supplement, calculated at the beginning of each state fiscal year, and payable in quarterly installments. The supplemental payment will increase reimbursement for CMHC provided clinics to 1.36 times the Medicare rate for such services, an amount that the state reasonably estimates to be comparable to that paid by private commercial payers. The payment will be subject to the clinic upper payment limit established at 42 CFR 447.321.

(4) Amount of Annual Supplemental Payment. Each CMHC's annual payment will be determined using the following methodology.

(A) For each service procedure where there is a corresponding Medicare fee for a CMHC provided clinic procedure, DMH will subtract the current Medicaid rate from the market proxy of 1.36 times the Medicare rate, then multiply the result by the number of units of service.

(B) For each service procedure where there is no corresponding Medicare fee for a CMHC provided clinic procedure, DMH will calculate the difference between what the CMHC received under the current Medicaid rate and what the CMHC would have received if paid the cost based fee used to approximate the commercial rate for such procedures, then multiply the result by the number of units of service.

(C) The amounts calculated in subsections (4)(A) and (4)(B) will be added together to determine each CMHC's total supplemental payment.

(D) In all years subsequent to state fiscal year 2012, the results of these calculations will be multiplied by a trend factor equal to the Consumer Price Index in the expenditure category Medical Care Services/Professional Services.

9 CSR 10-31.040

AUTHORITY: section 630.050, RSMo Supp. 2011, and sections 630.655 and 632.050, RSMo 2000.* Original rule filed Feb. 1, 2012, effective Aug. 30, 2012.

*Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.