Current through November 28, 2024
(a) Except for
services listed in (e) of this section, and as otherwise provided in (I) of
this section, the department will determine a rural health clinic's payment
rate or a federally qualified health center's payment rate based on the health
clinic's reasonable costs. Reasonable costs must be determined by using the
same methodology used under
42 U.S.C.
1395I(a)(3) and
42 C.F.R.
413.1 -
413.157. Costs must be related to
furnishing medically necessary and appropriate services to Medicaid-eligible
patients in accordance with
7
AAC 140.215. Costs may not include the cost of
providing prescription drugs. The department will consider only costs that are
related to providing Medicaid-eligible services to Medicaid-eligible patients,
and will exclude other costs. A health clinic may receive payment only for
services provided to a patient of the clinic by an employee or a contract
worker of the clinic. The department's payment for services provided by the
health clinic will be paid to the health clinic.
(b) Unless the department and a health clinic
make an agreement for the department to pay the clinic at the rates calculated
under (g) of this section, the department will pay the clinic in accordance
with
42 U.S.C.
1396a(bb)(1) - (5), adopted
by reference in 7 AAC 160.900. For state fiscal year 2018, the department will
not adjust for inflation, the payment rate under this subsection.
(c) If, consistent with the alternative
payment methodology provisions of
42 U.S.C.
1396 a(bb)(6), adopted by reference in 7 AAC
160.900, the department and a health clinic make an agreement for the
department to pay the clinic at the rate calculated under this subsection, the
department will calculate a prospective payment rate as follows:
(1) base rates will be calculated
prospectively,
(A) in an amount calculated on
a per-visit basis and equal to 100 percent of the inflated average of the
allowable costs
(i) of the health clinic of
furnishing services during the health clinic's fiscal years 1999 and 2000;
and
(ii) that are reasonable and
related to the cost of furnishing those services; and
(B) in accordance with the following formula:
(i) the clinic's total allowable and
reasonable cost of providing primary care and ambulatory services for fiscal
year 1999 will be inflated by the number set out in the first quarter 1999
publication of DRI-WEFA's
Healthcare Cost Review, Skilled
Nursing Facility Total Market Basket, inflated to 2001;
(ii) the clinic's total allowable and
reasonable cost of providing primary care and ambulatory services for fiscal
year 2000 will be inflated by the number set out in the first quarter 2000
publication of DRI-WEFA's
Healthcare Cost Review, Skilled
Nursing Facility Total Market Basket, inflated to 2001;
(iii) to obtain the base per-visit rate, the
sum of the numbers calculated in (i) and (ii) of this subparagraph will be
divided by the total number of visits as calculated under
7
AAC 145.710;
(iv) the base per visit rate obtained under
(iii) of this subparagraph will be adjusted to take into account any increase
or decrease in the scope of services during fiscal year 2001 that the
department has approved under (f) of this section;
(2) beginning with the health
clinic fiscal year 2003, and for each health clinic fiscal year that follows,
the payment rate as calculated in (1) of this subsection will be
(A) increased in that fiscal year by using
the first quarter publication of Global Insight's
Health care Cost
Review, Skilled Nursing Facility Total Market Basket for yearly
adjustment factors applied to health clinics; and for state fiscal year 2018,
the department will not adjust for inflation the payment rate under this
subparagraph; and
(B) adjusted for
that fiscal year to take into account any change in the scope of services that
the department has approved under (f) of this section, whether the change in
the scope of services is proposed for that fiscal year or occurred in the
preceding fiscal year;
(3) the payment rate calculated under this
subsection must result in a payment to the health clinic that is equal to or
greater than the amount required to be paid to the clinic under
42 U.S.C.
1396 a(bb)(1) - (6), adopted by reference in
7 AAC 160.900; if the payment rate calculated under this subsection is less
than that amount, the department will pay the health clinic under (b) of this
section; for state fiscal year 2018, the department will not adjust for
inflation the payment rate under (A) or (B) of this paragraph; to ensure
compliance with this paragraph, the department will evaluate annually the
(A) Medicare Economic Index as required by
42 U.S.C.
1396 a(bb)(3)(A), adopted by reference in 7
AAC 160.900; and
(B) number set out
in the first quarter publication of Global Insight's
Health-Care Cost
Review, Skilled Nursing Facility Total Market Basket;
(4) the department will annually
evaluate the payment rate calculated under this subsection to ensure it is
within the payment limit set under
42 C.F.R.
447.300-
447.371,
adopted by reference in 7 AAC 160.900.
(d) For purposes of this section, the
department will consider health clinic costs to be allowable costs if they are
documented costs as described in
42 C.F.R.
405.2468, adopted by reference in 7 AAC
160.900, after all adjustments, cost disallowances, and reclassifications have
been made, if those costs are reasonable in amount, if they are proper and
necessary for the efficient delivery of health clinic services, and if they are
not disallowed under AS 47.07, 7 AAC 105 - 7 AAC 160, or applicable federal
statutes or regulations. Allowable costs do not include overhead costs not
directly related to health clinic services, bad debts, charity care,
contractual allowances, return on equity, income taxes, or services and
supplies furnished to non-Medicaid recipients for free or without regard to the
recipient's ability to pay.
(e) In
establishing a payment rate under this section, the department will not include
services that are paid by a different payment rate methodology in 7 AAC 105 - 7
AAC 160. Services that are paid by a different payment rate methodology include
(1) prescription drugs subject to the drug
coverage limitations in
7
AAC 120.100 -
7
AAC 120.130 and paid in accordance with
7
AAC 145.400 -
7
AAC 145.410; and
(2) labor and delivery services provided by a
physician, a physician assistant, or an advanced practice registered nurse paid
in accordance with
7
AAC 145.050.
(f) Changes in the scope of services that are
provided by a health clinic will be used to adjust the per-visit rate for a
health clinic. These adjustments will be made upon the written notification of
the provider and approval by the department. The change in scope of services
must have increased or decreased a health clinic's cost per visit by more than
two and one-half percent. The change in the scope of services must be directly
related to a new or terminated program or service, and may not include general
increases or decreases in costs associated with programs that were already a
part of an established rate. The department will examine a written request for
a change in scope of services no more than 60 days after receipt to determine
if the change satisfies the requirements of this subsection. The health clinic
shall submit to the department a brief narrative describing the services that
are to be added or deleted or that result in an increase or decrease in the
scope of services. Additionally, a health clinic that proposes a change in the
scope of services for future implementation must provide a one-year budget that
specifies the change in the scope of services, shows the projected number of
visits, and provides revenue and expense projections associated with the
proposed change. If the department determines that a change in the scope of
services has occurred, the per-visit rate will be adjusted. A final decision
regarding the disposition of a request for a change in scope of services will
be given to a clinic in writing. If the health clinic notifies the department
(1) before implementing the change in the
scope of services that a change will occur, any adjustment will be made to
coincide with the implementation date of the change;
(2) after implementing the change that an
increase or decrease in the scope of services occurred, any adjustment will be
made to coincide with the
(A) date of
notification, for the addition of a category of service; a post-implementation
request for a rate adjustment must be received no later than 45 days after the
change in scope of services occurred; or
(B) implementation date of the change, for
the deletion of a category of service or a change in the intensity of a
service.
(g)
A health clinic that enrolls during or after health clinic fiscal year 2000,
and that
(1) submits cost data for a minimum
of six months during the health clinic fiscal year 1999 and 2000 period, may
request payment at a per-visit rate that is based on the submitted
data;
(2) does not submit cost data
for a minimum of six months, will be paid a per-visit rate equal to the
statewide weighted average of the total Medicaid per-visit payment rates made
to health clinics; the base per-visit rate will be re-determined
(A) after Medicare cost reports for health
clinic fiscal years one and two are submitted and are reviewed by the
department, and will be inflated in accordance with (c) of this section, except
that the first two fiscal years of data that the clinic has available will be
substituted for fiscal years 1999 and 2000; and
(B) to allow payments for each succeeding
health clinic fiscal year to be established by using the base per-visit rate
set for the previous clinic fiscal year, and increasing that rate by the
percentage increase in the number set out in the first quarter publication of
Global Insight's
Health-Care Cost Review, Skilled Nursing
Facility Total Market Basket; adjustments for that clinic fiscal year will be
made to take into account any increase or decrease in the scope of services
that the department has approved under (f) of this section, whether the change
in the scope of services is proposed for that fiscal year or occurred in the
preceding fiscal year.
(h) A health clinic may appeal, under
7
AAC 150.240, the final rate set by the department by
submitting a written request to the commissioner, so that the commissioner
receives the request no later than 30 days after the date that the final rate
agreement letter is issued.
(i) The
amount, duration, and scope of primary care and ambulatory medical services
provided by a health clinic are subject to the limits upon covered services
under 7 AAC 105 - 7 AAC 160 as applied to other Medicaid recipients.
(j) The department will pay a health clinic
that is outside this state and that provides covered services to a Medicaid
recipient eligible under 7 AAC 100 at the lesser of the
(1) per-visit rate established by the agency
responsible for Medicaid in the jurisdiction where the health clinic is
located; or
(2) the average
per-visit rate established by the department for health clinics in this
state.
(k) In this
section,
(1) "ambulatory services" has the
meaning given in
7
AAC 140.229;
(2) "change in the scope of services" means
(A) the addition of a category of service to,
or the deletion of a category of service from, those categories of service that
a rural health clinic or federally qualified health center provides;
or
(B) an increase or decrease in
the intensity of a category of service provided by a rural health clinic or
federally qualified health center that may be reasonably expected to span at
least one year; in this subparagraph, "intensity" means the cost of a category
of service due to a change in the level of medical care provided to the
population served by the rural health clinic or federally qualified health
center;
(3) "medically
necessary and appropriate" means
(A)
reasonably calculated to diagnose, correct, cure, alleviate, or prevent the
worsening of medical conditions that endanger life, cause suffering or pain,
result in illness or infirmity, threaten to cause or aggravate a disability, or
cause physical deformity or malfunction; and
(B) used because an equally effective more
conservative or substantially less costly course of medical diagnosis or
treatment is not available or suitable for the Medicaid recipient requesting
the service; for purposes of this subparagraph, "course of treatment" includes
mere observation or, if appropriate, no treatment at all.
(l) This section does not apply to
a federally qualified health center that elects to be reimbursed under
7
AAC 155.010(1).
Authority:AS
47.05.010
AS 47.07.030
AS 47.07.040
AS 47.07.070
AS
47.07.073
