Code of Colorado Regulations
2505 - Department of Health Care Policy and Financing
2505 - Medical Services Board (Volume 8; Medical Assistance, Children's Health Plan)
10 CCR 2505-10-8.700 - MEDICAL ASSISTANCE - SECTION 8.700 Federally Qualified Health Centers, Women's Health Services
Section 10 CCR 2505-10-8.700 - FEDERALLY QUALIFIED HEALTH CENTERS
Universal Citation: 2505 CO Code Regs 10 CCR 2505-10-8.700
Current through Register Vol. 47, No. 5, March 10, 2024
8.700.1 DEFINITIONS
8.700.1.A. Federally
Qualified Health Center (FQHC) means a hospital-based or freestanding center
that meets the FQHC definition found in Title 42 of the Code of Federal
Regulations, Part 405, Subpart X (2023). Title 42 of the Code of Federal
Regulations, Part 405, Subpart X (2023) is hereby incorporated by reference
into this rule. Such incorporation, however, excludes later amendments to or
editions of the referenced material. These regulations are available for public
inspection at the Department of Health Care Policy and Financing, 1570 Grant
Street, Denver, CO 80203. Pursuant to C.R.S.
24-4-103 (12.5)(V)(b), the agency
shall provide certified copies of the material incorporated at cost upon
request or shall provide the requestor with information on how to obtain a
certified copy of the material incorporated by reference from the agency of the
United States, this state, another state, or the organization or association
originally issuing the code, standard, guideline or rule:
8.700.1.B. Visit means a one-on-one,
face-to-face, interactive audio, interactive video, or interactive data
communication encounter between a center client and physician, dentist, dental
hygienist, dental therapist, physician assistant, nurse practitioner,
nurse-midwife, visiting nurse, clinical psychologist, podiatrist, clinical
social worker, licensed marriage and family therapist, licensed professional
counselor, or licensed addiction counselor providing the services set forth in
Section 8.700.3.A. Group sessions do not generate a billable encounter for any
FQHC services.
1. A visit includes a
one-on-one or face-to-face encounter, or an interactive audio, interactive
video, or interactive data communication encounter in accordance with Section
8.095, between a center client and a supervised person pursuing mental health
therapy licensure as a licensed clinical social worker, licensed professional
counselor, licensed marriage and family therapist, or psychologist in the state
of Colorado providing services set forth in Section 8.700.3.A. The supervised
person must hold a candidate permit as a licensed professional counselor or a
candidate permit as a licensed marriage and family therapist, or a candidate
permit as a psychologist, or a candidate permit as a clinical social worker
candidate (SWC), or a be a licensed social worker. Group sessions do not
generate a billable encounter for any FQHC services.
8.700.1.C. The visit definition includes
interactive audio (including but not limited to telephone and relay calls),
interactive video (including but not limited to interactive audiovisual
modalities), or interactive data communication (including but not limited to
live chat and excluding text messaging, electronic mail, and facsimile
transmission) encounters in accordance with Section 8.095.
1. Any health benefits provided through
interactive audio (including but not limited to telephone and relay calls),
interactive video (including but not limited to interactive audiovisual
modalities), or interactive data communication (including but not limited to
live chat and excluding text messaging, electronic mail, and facsimile
transmission) must meet the same standard of care as in-person care in
accordance with Section 8.095.
8.700.2 CLIENT CARE POLICIES
8.700.2.A The FQHCs health care services
shall be furnished in accordance with written policies that are developed with
the advice of a group of professional personnel that includes one or more
physicians and one or more physician assistants or nurse practitioners. At
least one member of the group shall not be a member of the FQHC
staff.
8.700.2.B The policies shall
include:
1. A description of the services the
FQHC furnishes directly and those furnished through agreement or arrangement.
See Section 8.700.3.A.3.
2.
Guidelines for the medical management of health problems that include the
conditions requiring medical consultation and/or client referral, the
maintenance of health care records and procedures for the periodic review and
evaluation of the services furnished by the FQHC.
3. Rules for the storage, handling and
administration of drugs and biologicals.
8.700.3 SERVICES
8.700.3.A The following services may be
provided by a certified FQHC:
1. General
services
a. Outpatient primary care services
that are furnished by a physician, dentist, dental hygienist, physician
assistant, nurse practitioner, nurse midwife visiting nurse, clinical
psychologist, podiatrist, clinical social worker, licensed marriage and family
therapist, licensed professional counselor, licensed addiction counselor or
supervised person pursuing mental health licensure as defined in their
respective practice acts.
i. Outpatient
primary care services that are furnished by a supervised person pursuing mental
health therapy licensure as a licensed clinical social worker, licensed
professional counselor, licensed marriage and family therapist, or psychologist
in the state of Colorado as defined in their respective practice acts.
b. Part-time or
intermittent visiting nurse care.
c. Services and medical supplies, other than
pharmaceuticals, that are furnished as a result of professional services
provided under Section 8.700.3.A.1.a and b.
2. Emergency services. FQHCs furnish medical
emergency procedures as a first response to common life-threatening injuries
and acute illness and must have available the drugs and biologicals commonly
used in life saving procedures.
3.
Services provided through agreements or arrangements. The FQHC has agreements
or arrangements with one or more providers or suppliers participating under
Medicare or Medicaid to furnish other services to clients, including physician
services (whether furnished in the hospital, the office, the client's home, a
skilled nursing facility, or elsewhere) and additional and specialized
diagnostic and laboratory services that are not available at the
FQHC.
8.700.3.B A
certified FQHC may also provide any service authorized for payment outside the
per visit encounter rate by Section 8.700.6.B.
8.700.4 PHYSICIAN RESPONSIBILITIES
8.700.4.A A physician
shall provide medical supervision and guidance for physician assistants and
nurse practitioners, prepare medical orders, and periodically review the
services furnished by the clinic. A physician shall be present at the clinic
for sufficient periods of time to fulfill these responsibilities and must be
available at all times by direct means of communications for advice and
assistance on patient referrals and medical emergencies. A clinic operated by a
nurse practitioner or physician assistant may satisfy these requirements
through agreements with one or more physicians.
8.700.5 ALLOWABLE COST
8.700.5.A The following types and items of
cost for primary care services are included in allowable costs to the extent
that they are covered and reasonable:
1.
Compensation for the services of a physician, dentist, dental hygienist,
physician assistant, nurse practitioner, nurse-midwife, visiting nurse,
qualified clinical psychologist, podiatrist, clinical social worker, licensed
marriage and family therapist, licensed professional counselor and licensed
addiction counselor and licensure candidates for clinical psychologist,
clinical social worker, licensed marriage and family therapist, and licensed
professional counselor who owns, is employed by, or furnishes services under
contract to an FQHC.
2.
Compensation for the duties that a supervising physician is required to
perform.
3. Costs of services and
supplies related to the services of a physician, dentist, dental hygienist,
physician assistant, nurse practitioner, nurse-midwife, visiting nurse,
qualified clinical psychologist, podiatrist, clinical social worker, licensed
marriage and family therapist, licensed professional counselor or licensed
addiction counselor.
4. Overhead
cost, including clinic or center administration, costs applicable to use and
maintenance of the entity, and depreciation costs.
5. Costs of services purchased by the clinic
or center.
8.700.5.B
Unallowable costs include but are not limited to expenses that are incurred by
an FQHC and that are not for the provision of covered services, according to
applicable laws, rules, and standards applicable to the Medical Assistance
Program in Colorado. An FQHC may expend funds on unallowable cost items, but
these costs may not be used in calculating the per visit encounter rate for
Medicaid clients.
Unallowable costs, include, but are not necessarily limited to, the following:
1. Offsite
Laboratory/X-Ray;
2. Costs
associated with clinics or cost centers which do not provide services to
Medicaid clients; and,
3. Costs of
services reimbursed separately from the FQHC encounter rate as described in
Section 8.700.6.B.
8.700.6 REIMBURSEMENT
8.700.6.A FQHCs shall be reimbursed separate
per visit encounter rates based on 100% of reasonable cost for physical health
services, dental services, and specialty behavioral health services. An FQHC
may be reimbursed for up to three separate encounters with the same client
occurring in one day and at the same location, so long as the encounters
submitted for reimbursement are any combination of the following: physical
health encounter, dental encounter, or specialty behavioral health encounter.
Distinct dental encounters are allowable only when rendered services are
covered and paid by the Department's dental Administrative Service Organization
(ASO). Distinct specialty behavioral health encounters are allowable only when
rendered services are covered and paid by either the Regional Accountable
Entity (RAE) or through the short-term behavioral health services in the
primary care setting policy.
8.700.6.B The following services are
reimbursed separately from the FQHC encounter rate. These services shall be
reimbursed in accordance with the following:
1. Long-Acting Reversible Contraception
(LARC) devices shall be reimbursed separately from the FQHC encounter rate. In
addition to payment of the encounter rate for the insertion of the device(s),
the LARC device(s) must be billed in accordance with Section 8.730 and shall be
reimbursed the lower of:
a. Submitted charges;
or
b. Fee schedule as determined
by the Department.
2.
Services provided in an inpatient hospital setting shall be reimbursed the
lower of:
a. Submitted charges; or
b. Fee schedule as determined by the
Department.
3. The
provision of complete dentures and partial dentures must be billed in
accordance with Section 8.201. and Section 8.202. and shall be reimbursed the
lower of:
a. Submitted charges; or
b. Fee schedule as determined by the
Department.
4. Dental
services provided in an outpatient hospital setting shall be reimbursed the
lower of:
a. Submitted charges; or
b. Fee schedule as determined by the
Department.
5. The
Prenatal Plus Program shall be billed and reimbursed in accordance with Section
8.748.
6. The Nurse Home Visitor
Program shall be billed and reimbursed in accordance with Section
8.749.
7. An FQHC that operates its
own pharmacy that serves Medicaid clients must obtain a separate Medicaid
billing number for pharmacy and bill all prescriptions utilizing this number in
accordance with Section 8.800.
8.
Antagonist injections for substance use disorders provided at the FQHC shall be
reimbursed the lower of:
a. Submitted charges;
or
b. Fee schedule as determined by
the Department.
9.
COVID-19 vaccine administration provided at the FQHC shall be reimbursed the
lower of:
a. Submitted charges; or
b. Fee schedule as determined by the
Department
10.
Monoclonal Antibody COVID-19 infusion administration provided at the FQHC shall
be reimbursed the lower of:
a. Submitted
charges; or
b. Fee schedule as
determined by the Department.
11. COVID-19 antiviral medication,
remdesivir, provided at the FQHC shall be reimbursed the lower of:
a. Submitted charges; or
b. Fee schedule as determined by the
Department.
8.700.6.C A physical health encounter, a
dental encounter, and a specialty behavioral health encounter on the same day
and at the same location shall count as three separate visits.
1. Encounters with more than one health
professional, and multiple encounters with the same health professional that
take place on the same day and at a single location constitute a single visit,
except when the client, after the first encounter, suffers illness or injury
requiring additional diagnosis or treatment.
8.700.6.D Encounter rates calculations
Effective July 1, 2018, FQHCs will be paid three separate encounter rates for three separate services: physical health services, dental services, and specialty behavioral health services. Physical health services are covered services reimbursed through the Department's MMIS, except the short-term behavioral health services in the primary care setting policy. Dental services are services provided by a dentist or dental hygienist that are reimbursed by the Department's dental ASO. Specialty behavioral health services are behavioral health services covered and reimbursed by either the RAE or by the MMIS through the short-term behavioral health services in the primary care setting policy. The Department will perform an annual reconciliation to ensure each FQHC has been paid at least their per visit Prospective Payment System (PPS) rate. If an FQHC has been paid below their per visit PPS rate, the Department shall make a one-time payment to make up for the difference.
1. The PPS rate is defined by Section 702 of
the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA)
included in the Consolidated Appropriations Act of 2000,
Public Law
106-554, Dec. 21, 2000. BIPA is incorporated
herein by reference. No amendments or later editions are incorporated.
Copies are available for a reasonable charge and for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Any material that has been incorporated by reference in this rule may be examined at any state publications depository library.
2. Each
alternative payment rate shall be the lower of the service specific annual rate
or the service specific base rate. The annual rate and the base rate shall be
calculated as follows:
a. The annual rate for
the physical health rate shall be the FQHCs current year's audited, calculated,
and inflated cost per visit for physical health services and visits. The annual
rate for the dental rate shall be the FQHCs current year's audited, calculated,
and inflated cost per visit for dental services and visits provided by a
dentist or dental hygienist. The annual rate for the specialty behavioral
health rate shall be the FQHCs current year's audited, calculated, and inflated
cost per visit for behavioral health services and visits either covered and
reimbursed by the RAE or by the short-term behavioral health services in the
primary care setting policy.
b. The
new base rates shall be the audited, calculated, inflated, and weighted average
encounter rate for each separate rate, for the past three years. Base rates are
recalculated (rebased) annually. Initial Base rates shall be calculated when
the Department has two year's data of costs and visits.
c. Beginning July 1, 2020, a portion of the
FQHCs physical health alternative payment methodology rates are at-risk based
on the FQHC's quality modifier. An FQHC's quality modifier is determined by the
FQHC's performance on quality indicators in the previous Calendar
Year.
3. New FQHCs shall
file a preliminary FQHC Cost Report with the Department. Data from the
preliminary report shall be used to set reimbursement base rates for the first
year. The base rates shall be calculated using the audited cost report showing
actual data from the first fiscal year of operations as an FQHC. These shall be
the FQHCs base rates until the FQHC's final base rates are set.
a. New base rates may be calculated using the
most recent audited Medicaid FQHC cost report for those FQHCs that have
received their first federal Public Health Service grant with the three years
prior to rebasing, rather than using the inflated weighted average of the most
recent three years audited encounter rates.
4. The Department shall audit the FQHC cost
report and calculate the new annual and base reimbursement rates. If the cost
report does not contain adequate supporting documentation, the FQHC shall
provide requested documentation within ten (10) business days of request.
Unsupported costs shall be unallowable for the calculation of the FQHCs new
encounter rate.
a. Freestanding and
hospital-based FQHCs shall file the Medicaid cost reports with the Department
on or before the 90th day after the end of the FQHCs' fiscal year. FQHCs shall
use the Medicaid FQHC Cost Report developed by the Department to report annual
costs and encounters. An extension of up to 75 days may be granted based upon
circumstances. Failure to submit a cost report within 180 days after the end of
a freestanding FQHCs' fiscal year shall result in suspension of
payments.
b. The new reimbursement
encounter rates for FQHCs shall be effective 120 days after the FQHCs fiscal
year end. The old reimbursement encounter rates (if less than the new audited
rate) shall remain in effect for an additional day above the 120-day limit for
each day the required information is late; if the old reimbursement encounter
rates are more than the new rate, the new rates shall be effective the 120th
day after the FQHCs fiscal year end.
c. Effective December 11, 2020, FQHC cost
reports with fiscal year ends between May 31, 2020 and March 31, 2021 will be
set using the previous year's rates multiplied by the Medicare Economic Index
(MEI).
d. Effective September 28,
2021, FQHC cost reports with fiscal year ends between May 31, 2021 and March
31, 2022 will be set using the previous year's rates multiplied by
2.7%.
e. Starting with FQHC cost
reports with fiscal year end May 31, 2022 the Department will restart the base
rate setting process. For the first cost report submitted by an FQHC with
fiscal year end May 31, 2022 and after, base rates will be set based on one
year's worth of data. For the second cost report submitted by an FQHC with
fiscal year end May 31, 2022 and after, base rates will be set as a weighted
average of two years' worth of data. After this, base rates will be set as
specified in 8.700.6.D.2.
5. If an FQHC changes its scope of service
after the year in which its base PPS rate was determined, the Department will
adjust the FQHC's PPS rate in accordance with section 1902(bb) of the Social
Security Act.
a. An FQHC must apply to the
Department for an adjustment to its PPS rate whenever there is a documented
change in the scope of service of the FQHC. The documented change in the scope
of service of the FQHC must meet all of the following conditions:
i. The increase or decrease in cost is
attributable to an increase or decrease in the scope of service that is a
covered benefit, as described in Section 1905(a)(2)(C) of the Social Security
Act, and is furnished by the FQHC.
ii. The cost is allowable under Medicare
reasonable cost principles set forth in 42 CFR Part 413.5.
iii. The change in scope of service is a
change in the type, intensity, duration, or amount of services, or any
combination thereof.
iv. The net
change in the FQHC's per-visit encounter rate equals or exceeds 3% for the
affected FQHC site. For FQHCs that file consolidated cost reports for multiple
sites in order to establish the initial PPS rate, the 3% threshold will be
applied to the average per-visit encounter rate of all sites for the purposes
of calculating the cost associated with a scope-of-service change.
v. The change in scope of service must have
existed for at least a full six (6) months.
b. A change in the cost of a service is not
considered in and of itself a change in scope of service. The change in cost
must meet the conditions set forth in Section 8.700.6.D.5.b and the change in
scope of service must include at least one of the following to prompt a
scope-of-service rate adjustment. If the change in scope of service does not
include at least one of the following, the change in the cost of services will
not prompt a scope-of-service rate adjustment.
i. The addition of a new service not
incorporated in the baseline PPS rate, or deletion of a service incorporated in
the baseline PPS rate;
ii. The
addition or deletion of a covered Medicaid service under the State
Plan;
iii. Changes necessary to
maintain compliance with amended state or federal regulations or regulatory
requirements;
iv. Changes in
service due to a change in applicable technology and/or medical practices
utilized by the FQHC;
v. Changes
resulting from the changes in types of patients served, including, but not
limited to, populations with HIV/AIDS, populations with other chronic diseases,
or homeless, elderly, migrant, or other special populations that require more
intensive and frequent care;
vi.
Changes resulting from a change in the provider mix, including, but not limited
to:
a. A transition from mid-level providers
(e.g. nurse practitioners) to physicians with a corresponding change in the
services provided by the FQHC;
b.
The addition or removal of specialty providers (e.g. pediatric, geriatric, or
obstetric specialists) with a corresponding change in the services provided by
the FQHC (e.g. delivery services);
c. Indirect medical education adjustments and
a direct graduate medical education payment that reflects the costs of
providing teaching services to interns and/or residents; or,
d. Changes in operating costs attributable to
capital expenditures (including new, expanded, or renovated service
facilities), regulatory compliance measures, or changes in technology or
medical practices at the FQHC, provided that those expenditures result in a
change in the services provided by the FQHC.
c. The following items do not prompt a
scope-of-service rate adjustment:
i. An
increase or decrease in the cost of supplies or existing services;
ii. An increase or decrease in the number of
encounters;
iii. Changes in office
hours or location not directly related to a change in scope of
service;
iv. Changes in equipment
or supplies not directly related to a change in scope of service;
v. Expansion or remodel not directly related
to a change in scope of service;
vi. The addition of a new site, or removal of
an existing site, that offers the same Medicaid-covered services;
vii. The addition or removal of
administrative staff;
viii. The
addition or removal of staff members to or from an existing service;
ix. Changes in salaries and benefits not
directly related to a change in scope of service;
x. Change in patient type and volume without
changes in type, duration, or intensity of services;
xi. Capital expenditures for losses covered
by insurance; or,
xii. A change in
ownership.
d. An FQHC
must apply to the Department by written notice within ninety (90) days of the
end of the FQHCs fiscal year in which the change in scope of service occurred,
in conjunction with the submission of the FQHC's annual cost report. Only one
scope-of-service rate adjustment will be calculated per year. However, more
than one type of change in scope of service may be included in a single
application.
e. Should the
scope-of-service rate application for one year fail to reach the threshold
described in Section 8.700.6.D.5.b.4, the FQHC may combine that year's change
in scope of service with a valid change in scope of service from the next year
or the year after. For example, if a valid change in scope of service that
occurred in FY 2016 fails to reach the threshold needed for a rate adjustment,
and the FQHC implements another valid change in scope of service during FY2018,
the FQHC may submit a scope-of-service rate adjustment application that
captures both of those changes. An FQHC may only combine changes in scope of
service that occur within a three-year time frame, and must submit an
application for a scope-of-service rate adjustment as soon as possible after
each change has been implemented. Once a change in scope of service has
resulted in a successful scope-of-service rate adjustment, either individually
or in combination with another change in scope of service, that change may no
longer be used in an application for another scope-of-service rate
adjustment.
f. The documentation
for the scope-of-service rate adjustment is the responsibility of the FQHC. Any
FQHC requesting a scope-of-service rate adjustment must submit the following to
the Department:
i. The Department's
application form for a scope-of-service rate adjustment, which includes:
a. The provider number(s) that is/are
affected by the change(s) in scope of service;
b. A date on which the change(s) in scope of
service was/were implemented;
c. A
brief narrative description of each change in scope of service, including how
services were provided both before and after the change;
d. Detailed documentation such as cost
reports that substantiate the change in total costs, total health care costs,
and total visits associated with the change(s) in scope; and
e. An attestation statement that certifies
the accuracy, truth, and completeness of the information in the application
signed by an officer or administrator of the FQHC;
ii. Any additional documentation requested by
the Department. If the Department requests additional documentation to
calculate the rate for the change(s) in scope of service, the FQHC must provide
the additional documentation within thirty (30) days. If the FQHC does not
submit the additional documentation within the specified timeframe, the
Department, at its discretion, may postpone the implementation of the
scope-of-service rate adjustment.
g. The reimbursement rate for a
scope-of-service change applied for January 30, 2017 or afterwards will be
calculated as follows:
i. The Department will
first verify the total costs, the total covered health care costs, and the
total number of visits before and after the change in scope of service. The
Department will also calculate the Adjustment Factor (AF = covered health care
costs/total cost of FQHC services) associated with the change in scope of
service of the FQHC. If the AF is 80% or greater, the Department will accept
the total costs as filed by the FQHC. If the AF is less than 80%, the
Department will reduce the costs other than covered health care costs (thus
reducing the total costs filed by the FQHC) until the AF calculation reaches
80%. These revised total costs will then be the costs used in the
scope-of-service rate adjustment calculation.
ii. The Department will then use the
appropriate costs and visits data to calculate the adjusted PPS rate. The
adjusted PPS rate will be the average of the costs/visits rate before and after
the change in scope of service, weighted by visits.
iii. The Department will calculate the
difference between the current PPS rate and the adjusted PPS rate. The "current
PPS rate" means the PPS rate in effect on the last day of the reporting period
during which the most recent scope-of-service change occurred.
iv. The Department will check that the
adjusted PPS rate meets the 3% threshold described above. If it does not meet
the 3% threshold, no scope-of-service rate adjustment will be implemented.
v. Once the Department has
determined that the adjusted PPS rate has met the 3% threshold, the adjusted
PPS rate will then be increased by the Medicare Economic Index (MEI) to become
the new PPS rate.
h. The
Department will review the submitted documentation and will notify the FQHC in
writing within one hundred twenty (120) days from the date the Department
received the application as to whether a PPS rate change will be implemented.
Included with the notification letter will be a rate-setting statement sheet,
if applicable. The new PPS rate will take effect one hundred twenty (120) days
after the FQHC's fiscal year end.
i. Changes in scope of service, and
subsequent scope-of-service rate adjustments, may also be identified by the
Department through an audit or review process.
i. If the Department identifies a change in
scope of services, the Department may request the documentation as described in
Section 8.700.6.D.5.g from the FQHC. The FQHC must submit the documentation
within ninety (90) days from the date of the request.
ii. The rate adjustment methodology will be
the same as described in Section 8.700.6.D.5.h.
iii. The Department will review the submitted
documentation and will notify the FQHC by written notice within one hundred
twenty (120) days from the date the Department received the application as to
whether a PPS rate change will be implemented. Included with the notification
letter will be a rate-setting statement sheet, if applicable.
iv. The effective date of the
scope-of-service rate adjustment will be one hundred twenty (120) days after
the end of the fiscal year in which the change in scope of service occurred.
j. An FQHC may request a
written informal reconsideration of the Department's decision of the PPS rate
change regarding a scope-of-service rate adjustment within thirty (30) days of
the date of the Department's notification letter. The informal reconsideration
must be mailed to the Department of Health Care Policy and Financing, 1570
Grant St, Denver, CO 80203. To request an informal reconsideration of the
decision, an FQHC must file a written request that identifies specific items of
disagreement with the Department, reasons for the disagreement, and a new rate
calculation. The FQHC should also include any documentation that supports its
position. A provider dissatisfied with the Department's decision after the
informal reconsideration may appeal that decision through the Office of
Administrative Courts according to the procedures set forth in
10 CCR
2505-10 Section 8.050.3, PROVIDER APPEALS.
6. The performance of physician
and mid-level medical staff shall be evaluated through application of
productivity standards established by the Centers for Medicare and Medicaid
Services (CMS) in CMS Publication 27, Section 503; "Medicare Rural Health
Clinic and FQHC Manual". If an FQHC does not meet the minimum productivity
standards, the productivity standards established by CMS shall be used in the
FQHCs' rate calculation.
7. Pending
federal approval, the Department will offer a second Alternative Payment
Methodology (APM 2) that will reimburse FQHCs a Per Member Per Month (PMPM)
rate. FQHCs may opt into APM 2 annually. This reimbursement methodology will
convert the FQHC's current Physical Health cost per visit rate into an
equivalent PMPM rate using historical patient utilization, member designated
attribution, and the Physical Health cost per visit rate for the specific FQHC.
Physical health services rendered to patients not attributed to the FQHC, or
attributed based on geographic location, will pay at the appropriate encounter
rate. Dental and specialty behavioral health services for all patients will be
paid at the appropriate encounter rate. Year 2 rates for FQHCs participating in
APM 2 will be set using trended data. Year 3 rates will be set using actual
data.
8. The Department will
perform an annual reconciliation to ensure the PMPM reimbursement compensates
APM 2 providers in an amount that is no less than their PPS per visit rate. The
Department shall perform PPS reconciliations should the FQHC participating in
APM 2 realize additional cost, not otherwise reimbursed under the PMPM,
incurred as a result of extraordinary circumstances that cause traditional
encounters to increase to a level where PMPM reimbursement is not sufficient
for the operation of the FQHC.
9.
PMPM and encounter rates for FQHC participating in APM 2 shall be effective on
the 1st day of the month that falls at least 120 days after an FQHC's fiscal
year end.
8.700.6.E The
Department shall notify the FQHC of its rates.
8.700.8 REIMBURSEMENT FOR OUTSTATIONING ADMINISTRATIVE COSTS
8.700.8.A The
Department shall reimburse freestanding FQHCs for reasonable costs associated
with assisting clients in the Medicaid application process. Beginning with the
2019 Cost Report Cycle, this outstationing payment shall be made based upon
actual cost and is included as an allowable cost in an FQHC cost
report.
8.700.8.B
1. Hospitals with hospital-based FQHCs shall
receive federal financial participation for reasonable costs associated with
assisting potential beneficiaries in the Medicaid application process. For any
hospital-based FQHC Medicaid cost report audited and finalized after July 1,
2005, Denver Health Medical Center shall receive federal financial
participation for eligible expenditures. To receive the federal financial
participation, Denver Health Medical Center shall provide the state's share of
the outstationing payment by certifying that the audited administrative costs
associated with outstationing activities are eligible Medicaid public
expenditures. Such certifications shall be sent to the Safety Net Programs
Manager.
2. Hospitals with
hospital-based FQHCs shall receive federal financial participation for
reasonable costs associated with assisting potential beneficiaries in the
Medicaid application process. Effective with the hospital cost report year 2010
and forward, the Department will make an interim payment to Denver Health
Medical Center for estimated reasonable costs associated with outstationing
activities based on the costs included in the as-filed Medicare cost report.
This interim payment will be reconciled to actual costs after the cost report
is audited. Denver Health Medical Center shall receive federal financial
participation for eligible expenditures. To receive the federal financial
participation, Denver Health Medical Center shall provide the state's share of
the outstationing payment by certifying that the interim estimated
administrative costs and the final audited administrative costs associated with
outstationing activities are eligible Medicaid public expenditures. Such
certifications shall be sent to the Safety Net Programs Manager.
8.711.1 through 8.712 Repealed, effective June 30, 2005
Disclaimer: These regulations may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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