Reimbursement

Reimbursement The Division of Medicaid reimburses Federally Qualified Health Center (FQHC) providers at a prospective payment system (PPS) rate per encounter and/or an alternative payment methodology (APM). A. The Division of Medicaid uses the PPS methodology for reimbursement to FQHC providers per encounter as described below: 1. For services provided on and after January 1, 2001, during calendar year 2001, payment for services shall be calculated, on a per visit basis, in an amount equal to one hundred percent (100%) of the average of the FQHC’s reasonable costs of providing Medicaid covered services during fiscal years 1999 and 2000. The average rate will be computed from the FQHC Medicaid cost reports by applying a forty percent (40%) weight to fiscal year 1999 and a sixty percent (60%) weight to fiscal year 2000 and adding those rates together. If an FQHC first qualifies during fiscal year 2000, the rate will only be computed from the fiscal year 2000 Medicaid cost report. The PPS baseline calculation shall include the cost of all Medicaid covered services including other ambulatory services that were previously paid under a fee-for-service basis. This rate will be adjusted to take into account any increase or decrease in the scope of services furnished by the FQHC during fiscal year 2001. 2. Payment rates may be adjusted by the Division of Medicaid pursuant to changes in federal and/or state laws or regulations. 3. Beginning in calendar year 2002, and for each calendar year thereafter, the FQHC is entitled to the payment amount, on a per visit basis, to which the FQHC was entitled to in the previous year, increased by the percentage increase in the Medicare Economic Index (MEI) for primary care services for that calendar year, and adjusted to take into account any increase or decrease in the scope of services furnished by the FQHC during that calendar year. The rate will be retroactively adjusted to reflect the MEI. 4. New centers that qualify for the FQHC program after January 1, 2001, will be reimbursed the initial PPS rate which will be based on the rates established for other FQHCs located in the same or adjacent area with a similar caseload. In the absence of a comparable FQHC, the rate for the new provider will be based on projected costs. After the FQHC’s initial year, a Medicaid cost report must be filed in accordance with the State Plan. The cost report will be desk reviewed and a rate will be calculated in an amount equal to one hundred percent (100%) of the FQHC’s reasonable costs of providing Medicaid covered services. The FQHC may be subject to a retroactive adjustment based on the difference between projected and actual allowable costs. Claims payments will be adjusted retroactive to the effective date of the original rate. For each subsequent calendar year, the payment rate will be equal to the rate established in the preceding calendar year, increased by the percentage increase in the MEI for primary care services that is published in the Federal Register in the fourth (4th) quarter of the preceding calendar year. B. The Division of Medicaid reimburses no more than four (4) encounters per beneficiary per day, provided that each encounter represents a different provider type, as the Division of Medicaid only reimburses for one (1) medically necessary encounter per beneficiary per day for each of the provider types listed in Miss. Admin. Code, Title 23, Part 211, Rule 1.2.A. except if the beneficiary experiences an illness or injury requiring additional diagnosis or treatment subsequent to the first encounter. Services provided by a nurse practitioner (NP) or physician assistant (PA) are reimbursed the full PPS rate. C. The Division of Medicaid reimburses for telehealth services which meet the requirements of Miss. Admin. Code Part 225 as follows: 1. An encounter for face-to-face telehealth services provided by the FQHC acting as a distant site provider. 2. A fee per completed transmission for telehealth services provided by the RHC acting as an originating site provider. The FQHC may not bill for an encounter visit unless a separately identifiable service is performed. The originating site facility fee will be paid at the existing fee-for-service rate in effect as of January 1, 2021. 3. Reimburses a FQHC for both the distant and originating provider site when such services are appropriately provided by the FQHC. D. An alternative payment methodology (APM) is an additional fee for certain services provided by the FQHC. 1. The Division of Medicaid reimburses an FQHC a fee in addition to the PPS rate when certain services are provided outside the Division of Medicaid’s regularly scheduled office hours. a) The Division of Medicaid defines regularly scheduled office hours as the hours between 8:00 a.m. and 5:00 p.m., Monday through Friday, excluding Saturday, Sunday and federal and state holidays, referred to in Miss. Admin. Code, Part 211, Rule 1.5.B.1. as “office hours”. b) To set regularly scheduled office hours outside of the Division of Medicaid’s definition of office hours, referred to in Miss. Admin. Code, Part 211, Rule 1.5.B.1. as “FQHC established office hours”. c) The FQHC must maintain records indicating FQHC established office hours and any changes including: 1) The date of the change, 2) The FQHC established office hours prior to the change, and 3) The new FQHC established office hours. d) The Division of Medicaid reimburses a fee in addition to the PPS rate when the encounter occurs: 1) During the FQHC’s established office hours which are set outside of the Division of Medicaid’s definition of office hours, or 2) Outside of the Division of Medicaid’s office hours or the FQHC’s established office hours only for a condition which is not life-threatening but warrants immediate attention and cannot wait to be treated until the next scheduled appointment during office hours or the FQHC established office hours. e) The Division of Medicaid reimburses only the appropriate PPS rate for an encounter scheduled during office hours or FQHC’s established office hours but not occurring until after office hours or FQHC established office hours. E. The Division of Medicaid reimburses an FQHC the PPS rate for the administration, insertion, and/or removal of certain categories of physician administered drugs (PADs), referred to as Clinician Administered Drug and Implantable Drug System Devices (CADDs), reimbursed under the pharmacy benefit to the extent the CADDs were not included in the calculation of the FQHC’s PPS rate. 1. CADDs are located on the Division of Medicaid’s website. 2. CADDs not included on the Division of Medicaid’s list of CADD-classified drugs will be denied if billed through the pharmacy point-of-sale (POS). F. If a physician employed by an FQHC provides physician services at an inpatient, outpatient, or emergency room hospital setting, the services must be billed under the individual physician’s Medicaid provider number and payment will be made directly to the physician. The financial arrangement between the physician and the FQHC must be handled through an agreement. G. Change in the Scope of Service 1. An FQHC must notify the Division of Medicaid in writing of any change in the scope of services by the end of the calendar year in which the change occurred, including decreases in scope of service. The Division of Medicaid will adjust an FQHC PPS rate if the following criteria are met: a) The FQHC can demonstrate there is a valid and documented change in the scope of services, and b) The change in scope of services results in at least a five percent (5%) increase or decrease in the FQHC PPS rate for the calendar year in which the change in scope of service took place. 2. An FQHC must submit a request for an adjustment to its PPS rate no later than one hundred eighty (180) days after the settlement date of FQHC Medicare final settlement cost report for the FQHC’s first full fiscal year of operation with the change in scope of services. The request must include the first final settlement cost report that includes twelve (12) months of costs for the new service. The adjustment will be granted only if the cost related to the change in scope of services results in at least a five percent (5%) increase or decrease in the FQHC PPS rate for the calendar year in which the change in scope of services took place. The cost related to a change in scope of services will be subject to reasonable cost criteria identified in accordance with federal regulations. 3. It is the responsibility of the FQHC to notify the Division of Medicaid of any change in the scope of service and provide the required proper and valid documentation to support the rate change. Such required documentation must include, at minimum, a detailed working trial balance demonstrating the increase or decrease in the FQHC’s PPS rate as a result of the change in scope of service. The Division of Medicaid will require the FQHC to provide such documentation in a format acceptable to the Division of Medicaid, including providing such documentation upon the Division of Medicaid’s pre-approved forms. The Division of Medicaid will also request additional information as it sees fit in order to sufficiently determine whether any change in scope of service(s) has occurred. The instructions and forms for submitting a request due to a change in scope of services located on the Division of Medicaid’s website. 4. Adjustments to the PPS rate for the increase or decrease in scope of services are reflected in the PPS rate for services provided in the calendar year following the calendar year in which the change in scope of services took place. The revised PPS rate generally cannot exceed the cost per visit from the most recent audited cost report. 5. The FQHC PPS rate will not be adjusted solely for a change in ownership status between freestanding and provider-based. H. Cost Reports 1. All FQHCs must submit to the Division of Medicaid a copy of their Medicare cost report for information purposes using the appropriate Medicare forms postmarked on or before the last day of the fifth (5th) month following the close of its Medicare cost reporting year. All filing requirements must be the same as for Title XVIII. When the due date of the cost report falls on a weekend or State of Mississippi or federal holiday, the cost report is due on the following business day. Extensions of time for filing cost reports will not be granted by the Division of Medicaid except for those supported by written notification of the extension granted by Title XVIII. Cost reports must be prepared in accordance with the policy for reimbursement of FQHCs. The FQHC’s cost report must include information on all satellite FQHCs. 2. If the Medicare cost report is not received within thirty (30) days of the due date, payment of claims will be suspended until receipt of the required report. This penalty can only be waived by the Executive Director of the Division of Medicaid. 3. An FQHC that does not file a Medicare cost report within six (6) calendar months after the close of its Medicare cost reporting year may be subject to cancellation of its provider agreement at the Division of Medicaid’s discretion. I. Medicaid payments are not made to any organization prior to the date of approval and execution of a valid Medicaid provider agreement. J. The Division of Medicaid reimburses an outside laboratory for laboratory services not listed in Miss. Admin. Code Part 211, Rule 1.2.C. separate from the PPS rate.