Independent Rural Health Clinic Program

PURPOSE: This rule establishes the regulatory basis for Title XIX Medicaid payment for Independent Rural Health Clinic Services. (1) Authority. This is the payment methodology used to reim burse providers in the MO HealthNet Independent Rural Health Clinic (RHC) program. (2) Qualifications. For a clinic to qualify for participation in the MO HealthNet independent RHC program, the clinic must be an independent facility, which means that the clinic may not be part of a hospital. However, a clinic may be located in the same building as a hospital, as long as there is no administra tive, organizational, financial, or other connection between the clinic and the hospital. (3) General Principles. (A) The MO HealthNet program shall reimburse independent RHC providers based on the reasonable cost of RHC-covered services related to the care of MO HealthNet participants (within program limitations) less any copayment or other third party liability amounts which may be due from MO HealthNet participants. (B) Reasonable costs shall be determined by the MO HealthNet Division based on desk review of the applicable cost reports and shall be subject to adjustment based on field audit. Reasonable costs shall not exceed the Medicare cost principles set forth in 42 CFR part 413. (4) Definitions. The following definitions shall apply for the purpose of this rule: (A) Desk review. The MO HealthNet Division’s review of a provider’s cost report without on-site audit; (B) Division. Unless otherwise designated, division refers to the MO HealthNet Division, the division of the Department of Social Services charged with administration of the MO HealthNet program; (C) Facility fiscal year. A facility’s twelve- (12-) month fiscal reporting period; (D) Generally accepted accounting principles (GAAP). Accounting conventions, rules, and procedures necessary to describe accepted accounting practice at a particular time promulgated by the authoritative body establishing those principles; (E) Medicaid cost report. The documents used for the pur pose of reporting the cost of rendering both covered and non-covered services for the facility’s fiscal year shall be the Medicare cost report forms CMS-222-92 and all worksheets sup plied by the division. If the Medicare CMS-222-92 is superseded by an alternate Medicare developed cost reporting tool during a facility’s fiscal year, that tool must be used for the facility’s fiscal year; and (F) Provider or facility. An independent RHC with a valid MO HealthNet participation agreement in effect with the Department of Social Services for the purpose of providing RHC services to Title XIX eligible participants. (5) Administrative Actions. (A) Annual Cost Report. 1. Each independent RHC shall complete a Medicaid cost report for the RHC’s twelve- (12-) month fiscal period. 2. Each RHC is required to complete and submit to the division an Annual Cost Report, including all worksheets, at tachments, schedules, and requests for additional information from the division. The cost report shall be submitted on forms provided by the division for that purpose. A. An independent RHC may be exempt from filing a Medicaid cost report if there is no MO HealthNet reimburse ment for the reporting period and the facility does not plan to bill the MO HealthNet program for any claims for the reporting period. The facility must submit a request to the division to waive the cost report filing requirement within five (5) calen dar months after the close of the facility’s reporting period. To request an exemption for the cost report filing requirement, the following information must be submitted to MHD for re view and approval: (I) A Low or No Missouri Medicaid Utilization Waiver Request Form. This form may be obtained from the division. The form must be fully completed and signed by an officer or administrator; and (II) Worksheet S series of the Medicare Cost Report. The applicable parts of the Worksheet S must be completed and signed by an officer or administrator. 3. All cost reports shall be completed in accordance with the requirements of this rule and the cost report instructions. Financial reporting shall adhere to GAAP except as otherwise specifically indicated in this rule. 4. The cost report shall be submitted within five (5) calen dar months after the close of the reporting period. An exten sion may be granted upon the request of the RHC and the ap proval of the division with an agreed upon date of completion. The request must be received in writing by the division prior to the end of the five (5) calendar-month period after the close of the reporting period. 5. In a change of ownership, the cost report for the closing period must be submitted within forty-five (45) calendar days of the effective date of the change of ownership, unless the change in ownership coincides with the seller’s fiscal year end, in which case the cost report must be submitted within five (5) months after the close of the reporting period. No extensions in the submitting of cost reports shall be granted when a change in ownership has occurred. 6. Cost reports shall be submitted and certified by an offi cer or administrator of the provider. Failure to file a cost report within the prescribed period, except as expressly extended in writing by the state agency, may result in the imposition of sanctions as described in 13 CSR 70-3.030. 7. Authenticated copies of agreements and other signifi cant documents related to the provider’s operation and provi sion of care to MO HealthNet participants must be attached to the cost report at the time of filing unless current and accurate copies have already been filed with the division. Material which must be submitted includes, but is not limited to, the following: A. Audit, review, or compilation statement prepared by an independent accountant, including disclosure statements and management letter; B. Contracts or agreements involving the purchase of fa cilities or equipment during the past five (5) years if requested by the division, the department, or its agents; C. Contracts or agreements with owners or related par ties; D. Contracts with consultants; E. Schedule detailing all grants, gifts, and income from endowments, including amounts, restrictions, and use; F. Documentation of expenditures, by line item, made under all restricted and unrestricted grants, gifts, or endow ments; G. Statement verifying the restrictions as specified by the donor, prior to donation, for all restricted grants; H. Leases or rental agreements, or both, related to the activities of the provider; I. Management contracts; J. Provider of service contracts; and K. Working trial balance actually used to prepare cost report with line number tracing notations or similar identifi cations. 8. Under no circumstance will the division accept amended cost reports for final settlement determination or adjustment after the date of the division’s notification of the final settle ment amount. (B) Records. 1. Maintenance and availability of records. A. A provider must keep records in accordance with GAAP and maintain sufficient internal control and documen tation to satisfy audit requirements and other requirements of this rule, including reasonable requests by the division or its authorized agent for additional information. B. Adequate documentation for all line items on the cost report shall be maintained by a provider. Upon request, all original documentation and records must be made available for review by the division or its authorized agent at the same site at which the services were provided. Copies of documen tation and records shall be submitted to the division or its authorized agent upon request. C. Records of related organization, as defined by 42 CFR 413.17, must be available upon demand. D. The division shall retain all uniform cost reports sub mitted by the independent RHCs for seven (7) years after the final settlement relating to a cost report is finalized, including the resolution of any subsequent appeals or other administra tive actions pertaining to the cost report. E. Each facility shall retain all financial information, data, and records relating to the operation and reimbursement of the facility for seven (7) years after the final settlement relat ing to a cost report is finalized, including the resolution of any subsequent appeals or other administrative actions pertaining to the cost report, and will maintain those reports pursuant to the record-keeping requirements of 42 CFR 413.20. 2. Adequacy of records. A. The division may suspend reimbursement or reduce payments to the appropriate fee schedule amounts if it deter mines that the RHC does not maintain records that provide an adequate basis to determine payments under MO HealthNet. B. The suspension or reduction continues until the RHC demonstrates to the division’s satisfaction that it does, and will continue to, maintain adequate records. (C) Audits. 1. Any cost report submitted may be subject to field audit by the division or its authorized agent. 2. A provider shall have available at the field audit loca tion one (1) or more knowledgeable persons authorized by the provider and capable of explaining the provider’s accounting and control system and cost report preparation, including all attachments and allocations. 3. If a provider maintains any records or documentation at a location which is not the same as the site where services were provided, the provider shall transfer the records to the same facility at which the services were provided, or the pro vider must reimburse the division or its authorized agent for reasonable travel costs necessary to perform any part of the field audit in any off-site location, if the location is acceptable to the division. (D) Change in Provider Status. The next payment due the provider after the division has received the notification of the termination of participation in the MO HealthNet program or change of ownership may be held by the division until the cost report is filed. Upon receipt of a cost report prepared in accordance with this rule, the payments that were withheld will be released. (6) Nonallowable Costs. Cost not reasonably related to RHC ser vices shall not be included in a provider’s costs. Nonallowable cost areas include, but are not limited to, the following: (A) Grants, gifts and income from endowments will be de ducted from total operating costs; (B) Bad debts, charity, and courtesy allowances; (C) Return on equity capital; (D) Capital cost increases due solely to changes in ownership; (E) Amortization on intangible assets, such as goodwill, leasehold rights, covenants, but excluding organizational costs; (F) Attorney fees related to litigation involving state, local, or federal governmental entities and attorney’s fees which are not related to the provision of RHC services, such as litigation related to disputes between or among owners, operators, or administrators; (G) Central office or pooled costs not attributable to the effi cient and economical operation of the facility; (H) Costs such as legal fees, accounting and administration costs, travel costs, and the costs of feasibility studies which are attributable to the negotiation or settlement of the sale or pur chase of any capital asset by acquisition or merger for which any payment has been previously made under the program; (I) Late charges and penalties; (J) Finder’s fees; (K) Fund-raising expenses; (L) Interest expense on intangible assets; (M) Religious items or supplies or services of a primarily re ligious nature performed by priests, rabbis, ministers, or other similar types of professionals. Costs associated with portions of the physical plant used primarily for religious functions are also nonallowable; (N) Research costs; (O) Salaries, wages, or fees paid to nonworking officers, em ployees, or consultants; (P) Value of services (imputed or actual) rendered by nonpaid workers or volunteers; and (Q) Costs of services performed in a satellite clinic, which does not have a valid MO HealthNet participation agreement with the Department of Social Services for the purpose of pro viding RHC services to Title XIX-eligible participants. (7) Interim Payments. (A) Independent RHCs, unless otherwise limited by regula tion, shall be reimbursed on an interim basis by MO HealthNet at the Medicare RHC rate. Interim payments shall be reduced by copayments and other third party liabilities. (B) An independent RHC contracted with a MO HealthNet managed care health plan shall be eligible for supplemen tal reimbursement up to its interim Medicare RHC rate. The supplemental reimbursement shall make up the difference between what the independent RHC would have been paid by the division based on the independent RHC’s Medicare rate and the total managed care health plan payments made to the clinic during the reporting period for covered services rendered to MO HealthNet managed care participants as set forth in the Managed Care contract. The supplemental reimbursement shall occur pursuant to the schedule agreed to by the division and the independent RHC but shall occur no less frequently than every four (4) months. Supplemental reimbursement shall be requested by the independent RHC on forms provided by the division. Supplemental reimbursement for managed care charges shall be considered interim reimbursement of the in dependent RHC’s MO HealthNet costs. (8) Final Settlement. (A) Final Settlement Determination. The state agency shall perform an annual desk review of the Medicaid cost reports for each RHC’s fiscal year and shall make the necessary payment adjustments (i.e., an additional payment or a recoupment), in order that the RHC’s net reimbursement shall equal reasonable costs as described in this section. 1. The total reimbursement amount due the RHC for cov ered services furnished to MO HealthNet participants is based on the allowable costs from the Medicaid cost report and is calculated as follows: A. The average cost per visit is calculated by dividing the total allowable cost incurred for the reporting period by total visits for RHC services furnished during this period. The average cost per visit is subject to tests of reasonableness which may be established in accordance with this rule or in corporated in the Allowable Cost per visit as determined on Worksheet C, Part I, line 9 of the cost report; and B. The total cost of RHC services furnished to MO HealthNet participants is calculated by multiplying the allow able cost per visit by the number of MO HealthNet visits for covered RHC services. 2. The total reimbursable cost is compared to the total in terim payments made to the RHC during the reporting period for MO HealthNet participants to determine the amount of the final settlement owed to or due from the RHC. The total interim payments include the amount paid by the division as deter mined from the division’s Medicaid Management Information System (MMIS) reports, the health plan payments as set forth in the Managed Care contract, and third party liability payments. 3. The total reimbursement will be subject to adjustment based on the results of a field audit which may be conducted by the MO HealthNet Division or its contracted agents. (B) Notification of Final Settlement. 1. The division will notify the RHC by letter of a cost report final settlement after the division completes the desk review of the cost report. The division’s notification letter will in clude the calculation of the final settlement and a Settlement Agreement, which the facility will sign and return to the divi sion indicating it agrees with the final settlement calculation. The division’s written notice to the RHC shall indicate if the final settlement results in the following: A. Underpayments. If the total reimbursement due the RHC exceeds the interim payments made for the reporting period, the division makes a lump-sum payment to the RHC to bring total payments into agreement with total reimburse ment due the RHC; and B. Overpayments. If the total interim payments made to a RHC for the reporting period exceed the total reimbursement due the RHC for the period, the division arranges with the RHC for repayment of the overpayment either by having it offset against the RHC’s subsequent interim payments, having the RHC repay by sending the division a payment, or a combina tion of offset and payment. 2. The RHC shall review the division’s notification letter and attachments and respond with a signed Settlement Agreement indicating it has accepted the final settlement within fifteen (15) calendar days of receiving the final settlement letter. If the RHC believes revisions to the division’s desk review and final settlement are necessary before it can accept the settlement, it must submit additional, amended, or corrected data within the fifteen- (15-) day deadline. Data received from the RHC after the fifteen- (15-) day deadline may not be considered by the division in determining if revisions to the final settlement are needed unless the RHC requests and receives an extension for submitting additional information prior to the end of the fifteen- (15-) day deadline. If the fifteen- (15-) day deadline passes without a response from the provider, the division will proceed with processing the final settlement as set forth in the division’s notification letter, and the final settlement shall be deemed final. The division may not accept an amended cost report or any other additional information to revise the cost report or final settlement after the final settlement is finalized. (C) The annual desk review will be subject to adjustment based on the results of a field audit which may be conducted by the division or its contracted agents. (9) Payment Assurance. (A) The state will pay each RHC, which furnishes the services in accordance with the requirements of the state plan, the amount determined for services furnished by the RHC accord ing to the standards and methods set forth in the regulations implementing the RHC Reimbursement Program. (B) RHC services provided for those participants having avail able Medicare benefits shall be reimbursed by MO HealthNet to the extent of the coinsurance and deductible as imposed under Title XVIII. (C) Where third-party payment is involved, MO HealthNet will be the payer of last resort. (D) Regardless of changes of ownership, management, con trol, leasehold interests by whatever form for any RHC previ ously certified for participation in the MO HealthNet program, the division will continue to make all the Title XIX payments directly to the entity with the RHC’s current provider number and hold the entity with the current provider number respon sible for all MO HealthNet liabilities. AUTHORITY: sections 208.201 and 660.017, RSMo 2016.* Emergency rule filed Aug. 20, 1993, effective Sept. 18, 1993, expired Jan. 15, 1994. Emergency rule filed Jan. 19, 1994, effective Jan. 29, 1994, expired Jan. 31, 1994. Original rule filed Aug. 20, 1993, effective Jan. 31, 1994. Amended: Filed Aug. 15, 2008, effective Feb. 28, 2009. Amended: Filed Oct. 17, 2018, effective June 30, 2019. *Original authority: 208.201, RSMo 1987, amended 2007 and 660.017, RSMo 1993, amended 1995.