Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.560,
216B.010,
216B.105,
216B.130,
216B.990, 42 C.F.R.
413,
438.60,
491, Subpart A, 440.130, 440.230, 447.3251, 45 C.F.R. 74.27, 48 C.F.R. Part 31,
42 U.S.C.
1396a, b, d
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services has responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed, or opportunity presented, by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the Department for
Medicaid Services' reimbursement policies for primary care center,
federally-qualified health center, federally-qualified health center
look-alike, and rural health clinic services.
Section 1. Definitions.
(1) "Advanced practice registered nurse" or
"APRN" is defined by
KRS
314.011(7).
(2) "Alternative payment methodology" or
"APM" means a reimbursement that is an alternative to the standard
reimbursement established in Section 3 of this administrative regulation in
accordance with
42 U.S.C.
1396a(bb)(6).
(3) "Audit" means an examination that may be
full or limited in scope of a federally-qualified health center's,
federally-qualified health center look-alike's, rural health clinic's, or
primary care center's:
(a) Financial
transactions, accounts, and reports; and
(b) Compliance with applicable Medicare and
Medicaid regulations, manual instructions, and directives.
(4) "Base year" means the first full fiscal
year following the effective date of an FQHC's, FQHC look-alike's, or RHC's
enrollment in the Medicaid program:
(a) In
which the FQHC, FQHC look-alike, or RHC has reached its maximum hours per day,
days per week, and weeks per year of intended operation as designated by the
FQHC, FQHC look-alike, or RHC; and
(b) Not to exceed twenty-four (24) months
past the effective date that the FQHC, FQHC look-alike, or RHC was enrolled
with the department.
(5)
"Certified psychologist with autonomous functioning" means an individual who is
a certified psychologist with autonomous functioning pursuant to
KRS
319.056.
(6) "Certified social worker" means an
individual who meets the requirements established in
KRS
335.080.
(7) "Change in scope of service" means a
change in the type, intensity, duration, or amount of service.
(8) "Department" means the Department for
Medicaid Services or its designated agent.
(9) "Enrollee" means a recipient who is
enrolled with a managed care organization for the purpose of receiving Medicaid
or KCHIP covered services.
(10)
"Federal financial participation" is defined in
42 C.F.R.
400.203.
(11) "Federally-qualified health center" or
"FQHC" is defined in
42 C.F.R.
405.2401.
(12) "Federally-qualified health center
look-alike" or "FQHC look-alike" means an entity that is currently approved by
the United States Department of Health and Human Services, Health Resources and
Services Administration, and the Centers for Medicare and Medicaid Services to
be a federally-qualified health center look-alike.
(13) "Final PPS rate" means an all-inclusive
reimbursement amount per visit for an FQHC, FQHC look-alike, or RHC that:
(a) Is unique to the FQHC, FQHC look-alike,
or RHC;
(b) Encompasses
reimbursement for all services rendered during the visit;
(c) Is based on:
1. Twelve (12) full months of Medicaid cost
report data in which the FQHC, FQHC look-alike, or RHC has reached its maximum
hours per day, days per week, and weeks per year of intended operation:
a. Submitted to the department by the FQHC,
FQHC look-alike, or RHC; and
b.
That has been reviewed and approved by the department; and
2. A paid claims listing corresponding to the
twelve (12) full months of Medicaid cost report data in which the FQHC, FQHC
look-alike, or RHC has reached its maximum hours per day, days per week, and
weeks per year of intended operation; and
(d) Is established by the
department.
(14) "Health
care provider" means, for:
(a) A primary care
center, an FQHC, an FQHC look-alike, or an RHC:
1. A licensed physician;
2. A licensed osteopathic
physician;
3. A licensed
podiatrist;
4. A licensed
optometrist;
5. An advanced
practice registered nurse;
6. A
licensed dentist or oral surgeon;
7. A physician assistant;
8. A licensed clinical social
worker;
9. A licensed
psychologist;
10. A licensed
marriage and family therapist;
11.
A licensed professional clinical counselor;
12. A licensed psychological
practitioner;
13. A certified
psychologist with autonomous functioning; or
14. A practitioner who is:
a. Authorized pursuant to
907
KAR 1:054 to provide services in a PCC, an FQHC, an
FQHC look-alike, or an RHC; and
b.
Not listed in subparagraphs 1 through 13 of this paragraph; or
(b) An FQHC or FQHC
look-alike, in addition to the professionals established in paragraph (a) of
this subsection:
1. A resident in the
presence of a teaching physician; or
2. A resident without the presence of a
teaching physician if:
a. The services are
furnished in an FQHC or FQHC look-alike in which the time spent by the resident
in performing patient care is included in determining any intermediary payment
to a hospital in accordance with
42 C.F.R.
413.75 through
413.83;
b. The resident furnishing the service
without the presence of a teaching physician has completed more than six (6)
months of an approved residency program;
c. The teaching physician:
(i) Does not direct the care of more than
four (4) residents at any given time; and
(ii) Directs care from a proximity that
constitutes immediate availability; and
d. The teaching physician:
(i) Has no other responsibilities at the
time;
(ii) Has management
responsibility for any recipient seen by the resident;
(iii) Ensures that the services furnished are
appropriate;
(iv) Reviews with the
resident, during or immediately after each visit by a recipient, the
recipient's medical history, physical examination, diagnosis, and record of
tests or therapies; and
(v)
Documents the extent of the teaching physician's participation in the review
and direction of the services furnished to each recipient.
(15)
"Interim PPS rate" means an all-inclusive per visit reimbursement amount
established by the department to pay an FQHC, FQHC look-alike, or an RHC for
covered services prior to the establishment of a final PPS rate.
(16) "Licensed clinical social worker" means
an individual who is currently licensed in accordance with
KRS
335.100.
(17) "Licensed marriage and family therapist"
is defined by
KRS
335.300(2).
(18) "Licensed professional clinical
counselor" is defined by
KRS
335.500(3).
(19) "Licensed psychological practitioner"
means an individual who meets the requirements established in
KRS
319.053.
(20) "Managed care organization" means an
entity for which the Department for Medicaid Services has contracted to serve
as a managed care organization as defined in
42
C.F.R. 438.2.
(21) "Medical Group Management Association
Medical Directorship and On-Call Compensation Survey" means a report developed
and owned by the Medical Group Management Association that:
(a) Highlights the critical relationship
between medical director compensation and time spent in the medical director
function;
(b) Aligns medical
director compensation with time spent as medical director; and
(c) Contains tables illustrating the
relationship of medical director salary to time spent in the medical director
function.
(22) "Medical
Group Management Association Physician Compensation and Production Survey
Report" means a report developed and owned by the Medical Group Management
Association that:
(a) Highlights the critical
relationship between physician salaries and productivity;
(b) Is used to align physician salaries and
benefits with provider production; and
(c) Contains:
1. Performance ratios illustrating the
relationship between compensation and production; and
2. Comprehensive and summary data tables that
cover many specialties.
(23) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907
KAR 3:130.
(24) "Medicare Economic Index" or "MEI" means
the economic index referred to in
42 U.S.C.
1395u(b)(3)(L).
(25) "Paid claims listing" means a report of
claims paid by the department for a given FQHC, FQHC look-alike, or
RHC.
(26) "Parent facility" means a
federally-qualified health center, federally-qualified health center
look-alike, or primary care center that is:
(a) Licensed and operating with a unique
Kentucky Medicaid program provider number;
(b) Operating under the same management as a
satellite facility; and
(c) The
original facility that existed prior to the existence of a satellite
facility.
(27) "PCC" or
"primary care center" means an entity that is currently licensed as a PCC in
accordance with
902 KAR 20:058.
(28) "Percentage increase in the MEI" is
defined in
42 U.S.C.
1395u(i)(3).
(29) "Physician assistant" is defined by
KRS
311.840(3).
(30) "PPS" means prospective payment
system.
(31) "Rate year" means, for
the purposes of the MEI, the twelve (12) month period beginning July 1 of each
year for which a rate is established for an FQHC, FQHC look-alike, or RHC under
the prospective payment system.
(32) "Reasonable cost" means:
(a) A cost as determined by the:
1. Applicable Medicare cost reimbursement
principles established in 42 C.F.R. Part 413, 45 C.F.R. 74.27, and 48 C.F.R.
Part 31 ; and
2. Medical Group
Management Association Physician Compensation and Production Survey Report for
the applicable year and region; and
(b) Costs determined to be reasonable in
accordance with a comprehensive desk review or audit.
(33) "Recipient" is defined by
KRS
205.8451(9).
(34) "RHC" or "rural health clinic" is
defined in
42 C.F.R.
405.2401(b).
(35) "Satellite facility" means a
federally-qualified health center, federally-qualified health center
look-alike, or primary care center that:
(a)
Is at a different location than the parent facility; and
(b) Operates under the same management as the
parent facility.
(36)
"Telehealth" means two (2)-way, real time interactive communication between a
patient and a physician or practitioner located at a distant site for the
purpose of improving a patient's health through the use of interactive
telecommunication equipment that includes, at a minimum, audio and video
equipment.
(37) "Visit" means an
encounter:
(a) Between a recipient or enrollee
and a health care provider during which an FQHC, FQHC look-alike, or RHC
service is delivered; and
(b) That
occurs:
1. In person; or
2. Via telehealth if authorized by
907 KAR
3:170.
Section 2. Provider Participation
Requirements.
(1)
(a) A participating FQHC, FQHC look-alike,
RHC, or PCC shall be currently:
1. Enrolled
in the Kentucky Medicaid Program in accordance with
907
KAR 1:672; and
2. Except as established in paragraph (c) of
this subsection, participating in the Kentucky Medicaid program in accordance
with
907
KAR 1:671.
(b) A satellite facility of an FQHC, an FQHC
look-alike, or a PCC shall:
1. Be currently
listed on the parent facility's license in accordance with
902 KAR 20:058;
2. Comply with the requirements regarding
extensions established in
902 KAR 20:058; and
3. Comply with
907
KAR 1:671.
(c) In accordance with
907
KAR 17:015, Section 3(3), an FQHC, FQHC look-alike,
RHC, or PCC that provides a service to an enrollee shall not be required to be
currently participating in the fee-for-service Medicaid Program.
(2)
(a) To be initially enrolled with the
department, an:
1. FQHC or FQHC look-alike
shall:
a. Enroll in accordance with
907
KAR 1:672; and
b. Submit to the department proof of its FQHC
or FQHC look-alike designation issued by the Centers for Medicare and Medicaid
Services; or
2. RHC
shall:
a. Enroll in accordance with
907
KAR 1:672; and
b. Submit to the department proof of its RHC
license issued by the Cabinet for Health and Family Services Office of
Inspector General.
(b) To remain enrolled and participating in
the Kentucky Medicaid program, an:
1. FQHC or
FQHC look-alike shall:
a. Comply with the
enrollment requirements established in
907
KAR 1:672;
b. Comply with the participation requirements
established in
907
KAR 1:671; and
c. Annually submit to the department proof of
its FQHC or FQHC look-alike designation issued by the Centers for Medicare and
Medicaid Services; or
2.
RHC shall:
a. Comply with the enrollment
requirements established in
907
KAR 1:672;
b. Comply with the participation requirements
established in
907
KAR 1:671; and
c. Annually submit to the department proof of
its RHC license issued by the Cabinet for Health and Family Services Office of
Inspector General.
(c) The requirements established in
paragraphs (a) and (b) of this subsection shall apply to a satellite facility
of an FQHC or FQHC look-alike.
(3)
(a) An
FQHC or FQHC look-alike that operates multiple satellite facilities shall:
1. List each satellite facility on the parent
facility's license in accordance with
902 KAR 20:058; and
2. Consolidate claims and cost report data of
its satellite facilities with the parent facility.
(b) A PCC that operates multiple satellite
facilities shall list each satellite facility on the parent facility's license
in accordance with
902 KAR 20:058.
(4) An FQHC, FQHC look-alike, RHC,
or PCC that has been terminated from federal participation shall be terminated
from Kentucky Medicaid program participation.
(5) A participating:
(a) FQHC and its staff shall comply with all
applicable federal laws and regulations, state laws and administrative
regulations, and local laws and regulations regarding the administration and
operation of an FQHC;
(b) FQHC
look-alike and its staff shall comply with all applicable federal laws and
regulations, state laws and administrative regulations, and local laws and
regulations regarding the administration and operation of an FQHC
look-alike;
(c) RHC and its staff
shall comply with all applicable federal laws and regulations, state laws and
administrative regulations, and local laws and regulations regarding the
administration and operation of an RHC; or
(d) PCC and its staff shall comply with all
applicable federal laws and regulations, state laws and administrative
regulations, and local laws and regulations regarding the administration and
operation of a PCC.
(6)
An FQHC, FQHC look-alike, RHC, or PCC performing laboratory services shall meet
the requirements established in
907
KAR 1:028 and
907
KAR 1:575.
Section 3. Standard Reimbursement for an
FQHC, FQHC look-alike, or RHC for a Visit by a Recipient Who is not an Enrollee
and that is Covered by the Department.
(1)
Except as established in Section 5 or Section 9 of this administrative
regulation, for a visit by a recipient who is not an enrollee and that is
covered by the department, the department shall reimburse:
(a) An FQHC, FQHC look-alike, or RHC a final
PPS rate as required by
42 U.S.C.
1396a(bb); or
(b) A satellite facility of an FQHC or FQHC
look-alike a final PPS rate as required by
42 U.S.C.
1396a(bb).
(2) Costs related to outpatient
drugs or pharmacy services shall be excluded from the PPS rate referenced in
subsection (1) of this section.
(3)
The department shall calculate a final PPS rate for a new FQHC, FQHC
look-alike, or RHC in accordance with Section 4 of this administrative
regulation.
(4) The department
shall adjust a final PPS rate:
(a) By the
percentage increase in the MEI applicable to FQHC, FQHC look-alike, or RHC
services on July 1 of each year;
(b) In accordance with Section 10 of this
administrative regulation:
1. Upon request and
documentation by an FQHC, FQHC look-alike, or RHC that there has been a change
in scope of services; or
2. Upon
review and determination by the department that there has been a change in
scope of services; and
(c) If necessary as a result of a desk review
or audit.
(5) A final
PPS rate established in accordance with this administrative regulation shall
not be subject to an end of the year cost settlement.
Section 4. Establishment of a Final PPS Rate
for a New FQHC, FQHC look-alike, or RHC.
(1)
(a) The department shall establish a final
PPS rate to reimburse a new FQHC, FQHC look-alike, or RHC 100 percent of its
reasonable cost of providing Medicaid covered services utilizing information
from the FQHC's, FQHC look-alike's, or RHC's base year upon completion of a
comprehensive desk review or audit of an FQHC's, FQHC look-alike's, or RHC's
Universal Cost Report.
(b) Except
for a time frame in which the department reimburses an FQHC, FQHC look-alike,
or RHC an interim PPS rate, the final PPS rate established for an FQHC, FQHC
look-alike, or RHC shall:
1. Be prospective;
and
2. Not settled to
cost.
(2) The
department shall determine the reasonable costs of an FQHC, FQHC look-alike, or
RHC based on the:
(a) Universal Cost Report:
1. Submitted by the FQHC, FQHC look-alike, or
RHC to the department and prepared by the FQHC, FQHC look-alike, or RHC in
accordance with the Universal Cost Report Instructions; and
2. That contains twelve (12) full months of
operating data for the designated base year;
(b) Department's review of the Universal Cost
Report referenced in paragraph (a) of this subsection; and
(c) Costs and visits as adjusted by the
department for full-time operation for a facility that is not in operation at
least forty (40) hours per week.
(3)
(a) An
FQHC, FQHC look-alike, or RHC shall submit a Universal Cost Report to the
department by the end of the fifth month following the end of the FQHC's, FQHC
look-alike's, or RHC's designated base year.
(b) The department shall:
1. Review the Universal Cost Report
referenced in paragraph (a) of this subsection submitted by an FQHC, FQHC
look-alike, or RHC within ninety (90) business days of receiving the Universal
Cost Report; and
2. Notify the
FQHC, FQHC look-alike, or RHC of the necessity of the FQHC, FQHC look-alike, or
RHC to submit additional documentation if necessary.
(c)
1. If
additional documentation is necessary to establish a final PPS rate, the FQHC,
FQHC look-alike, or RHC shall:
a. Provide the
additional documentation to the department within thirty (30) days of the
notification of need for additional documentation; or
b. Request an extension beyond thirty (30)
days to provide the additional documentation.
2. The department shall grant no more than
one (1) extension.
3. An extension
shall not exceed thirty (30) days.
(d)
1. If
the department requests additional documentation from an FQHC, FQHC look-alike,
or RHC but does not receive additional documentation or an extension request
within thirty (30) days, the department shall reimburse the FQHC, FQHC
look-alike, or RHC as it reimburses primary care centers that are not an FQHC,
FQHC look-alike, or RHC pursuant to Section 7 of this administrative regulation
until:
a. The additional documentation has
been received by the department; and
b. The department has established a final PPS
rate.
2. If an FQHC,
FQHC look-alike, or RHC does not submit a Universal Cost Report to the
department, the department shall reimburse the FQHC, FQHC look-alike, or RHC as
it reimburses primary care centers that are not an FQHC, FQHC look-alike, or
RHC pursuant to Section 7 of this administrative regulation until the FQHC,
FQHC look-alike, or RHC submits a Universal Cost Report to the
department.
(e) The
department shall review an FQHC's, FQHC look-alike's, or RHC's paid claims
Iisting for the period of time corresponding to the FQHC's, FQHC look-alike's,
or RHC's cost report period of time referenced in paragraph (a) of this
subsection.
(f)
1. If an FQHC, FQHC look-alike, or RHC has
submitted all necessary information to the department, within forty-five (45)
days of reviewing the FQHC's, FQHC look-alike's, or RHC's paid claims listing,
the department shall:
a. Establish a final PPS
rate for the FQHC, FQHC look-alike, or RHC; and
b. Notify the FQHC, FQHC look-alike, or RHC
in writing of the FQHC's, FQHC look-alike's, or RHC's:
(i) Final PPS rate; and
(ii) Appeal rights regarding the PPS final
rate.
2. To
allow adequate time for claim adjudication, a paid claims listing shall not be
requested until at least fourteen (14) months after an FQHC's, FQHC
look-alike's, or RHC's fiscal year end.
3. If an FQHC, FQHC look-alike, or RHC has
not submitted all necessary information to the department to establish a final
PPS rate, the department shall continue to pay the FQHC, FQHC look-alike, or
RHC as it pays primary care centers that are not an FQHC, FQHC look-alike, or
RHC pursuant to Section 7 of this administrative regulation.
(4) Along with a
Universal Cost Report, an FQHC, FQHC look-alike, or RHC shall submit to the
department a written statement of the FQHC's, FQHC look-alike's, or RHC's
maximum hours per day, days per week, and weeks per year of
operation.
Section 5.
Interim Reimbursement for a New FQHC, FQHC Look-alike, or RHC.
(1)
(a)
Until a final PPS rate is established for an FQHC, FQHC look-alike, or RHC, the
department shall reimburse the FQHC, FQHC look-alike, or RHC an interim PPS
rate based on the average final PPS rates of entities with similar
caseloads.
(b) To identify an
entity with a similar caseload, the department shall consider:
1. Entity type (FQHC, FQHC look-alike, or
RHC);
2. Managed care organization
region;
3. Operating hours per day,
days per week, and weeks per year; and
4. Specialty services, obstetrical services,
or hospital-based entities, if applicable.
(2) If no entity with a similar caseload
exists, the department shall establish an interim PPS rate using cost reporting
methods.
(3) After the department
establishes a final PPS rate for an FQHC, FQHC look-alike, or RHC, the
department shall retroactively adjust reimbursement to the FQHC, FQHC
look-alike, or RHC that was made on an interim basis to comport with the final
PPS rate.
(4) An FQHC, FQHC
look-alike, or RHC, upon enrolling with the Medicaid Program, shall submit in
writing to the department a statement stating the FQHC's, FQHC look-alike's, or
RHC's maximum hours per day, days per week, and weeks per year of
operation.
Section 6.
Reimbursement for Services or Drugs Provided to an Enrollee by a PCC That is
Not an FQHC, FQHC Look-Alike, or RHC and that are Covered by an MCO.
(1) For a service or drug provided to an
enrollee by a PCC that is not an FQHC, FQHC look-alike, or RHC and that is
covered by an MCO, the PCC's reimbursement shall be the reimbursement
established pursuant to an agreement between the PCC and the managed care
organization with whom the enrollee is enrolled.
(2) The department shall not supplement the
reimbursement referenced in subsection (1) of this section.
Section 7. Reimbursement for
Services or Drugs Provided to a Recipient by a PCC That is Not an FQHC, FQHC
Look-Alike, or RHC and that are Covered by the Department.
(1)
(a) For
a service or drug provided to a recipient that is not an enrollee by a PCC that
is not an FQHC, FQHC look-alike, or RHC, the department shall reimburse the
rate or reimbursement established for the service or drug on the current
Kentucky-specific Medicare Physician Fee Schedule.
(b)
1.
Except as provided in subparagraph 3. of this paragraph, if no rate or
reimbursement exists on the Kentucky-specific Medicare Physician's Fee schedule
for a service or drug referenced in paragraph (a) of this subsection, the
department shall reimburse for the service or drug the same amount that the
department reimburses for the service or drug pursuant to the applicable
administrative regulation established in Title 907 KAR.
2. For example, if no reimbursement exists on
the current Kentucky-specific Medicare Physician Fee Schedule for a:
a. Dental service, the department shall
reimburse for the dental service pursuant to
907 KAR
1:626; or
b. Given physician's service, the department
shall reimburse for the service pursuant to
907 KAR
3:010.
3. The department shall reimburse a rate
equal to seventy-five (75) percent of the rate it pays a physician pursuant to
907 KAR
3:010 for a physician's service that:
a. Does not exist on the current
Kentucky-specific Medicare Physician Fee Schedule; and
b. Is provided by an APRN or physician
assistant.
(2) The reimbursement referenced in
subsection (1) of this section shall not exceed the federal upper payment limit
determined in accordance with
42
C.F.R. 447.321.
(3)
(a) The
coverage provisions and requirements established in
907 KAR
3:005 shall apply to a service or drug provided by a
PCC.
(b) If a Medicare coverage
provision or requirement exists regarding a given service or drug that
contradicts a provision or requirement established in
907 KAR
3:005, the provision or requirement established in
907 KAR
3:005 shall supersede the Medicare provision or
requirement.
Section
8. Supplemental Reimbursement for FQHC Visits, FQHC Look-Alike
Visits, and RHC Visits. If a managed care organization's reimbursement to an
FQHC, FQHC look-alike, or RHC for a visit by an enrollee to the FQHC, FQHC
look-alike, or RHC is less than what the FQHC, FQHC look-alike, or RHC would
receive pursuant to Sections 3, 4, 5, or 9 of this administrative regulation,
the department shall supplement the reimbursement made by the managed care
organization in a manner that:
(1) Equals the
difference between what the managed care organization reimbursed and what the
reimbursement would have been if it had been made in accordance with Sections
3, 4, 5, or 9 of this administrative regulation;
(2) Is in accordance with
42 U.S.C.
1396a(bb)(5)(A);
and
(3) Ensures that total
reimbursement does not exceed the federal upper payment limit in accordance
with
42 C.F.R.
447.304.
Section 9. Alternative Payment Methodology
for an FQHC, FQHC Look-alike, or RHC.
(1)
(a) The department shall pay to an FQHC, FQHC
look-alike, or RHC, for which a final PPS rate exists, an alternative payment
methodology if the FQHC, FQHC look-alike, or RHC notifies the department in
writing that it requests to receive the alternate reimbursement.
(b)
1. The
APM shall equal 125 percent of the Medicare upper payment limit for rural
health clinics in effect on September 30, 2014.
2. The APM referenced in subparagraph 1 of
this paragraph shall not be adjusted for inflation.
(c) An FQHC, FQHC look-alike, or RHC that had
an interim PPS rate prior to November 1, 2015 may request the APM as an interim
PPS rate until the FQHC's, FQHC look-alike's, or RHC's final PPS rate is
established.
(2)
(a) An APM established in this section shall
be effective for dates of service beginning with the date requested in writing
by an FQHC, FQHC look-alike, or RHC except as established in paragraph (b) of
this subsection.
(b) An APM
effective date shall not precede the date in which the department received the
written request for the APM.
Section 10. Change in Scope and Final PPS
Rate Adjustment.
(1)
(a) If an FQHC, FQHC look-alike, or RHC
changes its scope of services after the base year, the department shall adjust
the FQHC's, FQHC look-alike's, or RHC's final PPS rate if the change in scope
qualifies for an adjustment in accordance with this section upon departmental
review and approval of the change in scope.
(b) An adjustment to a final PPS rate
resulting from a change in scope that occurred after an FQHC's, FQHC
look-alike's, or RHC's base year shall be effective to the date that the change
in scope occurred.
(c)
1. A revised PPS rate shall be calculated in
accordance with the MAP 100501.
2.
A revised PPS rate shall not be rebased.
(2) A change in scope of service shall be
restricted to:
(a) Adding or deleting a
covered service;
(b) Increasing or
decreasing the intensity of a covered service pursuant to subsection (5) of
this section; or
(c) A statutory or
regulatory change that materially impacts the costs or visits of an FQHC, FQHC
look-alike, or RHC.
(3)
The following items individually shall not constitute a change in scope:
(a) A general increase or decrease in the
costs of existing services;
(b) A
reduction or an expansion of hours per day, days per week, or weeks per
year;
(c) An addition of a new site
that provides the same Medicaid covered services;
(d) A wage increase;
(e) A renovation or other capital
expenditure;
(f) A change in
ownership; or
(g) An addition or
deletion of a service provided by a non-licensed professional or
specialist.
(4)
(a) An addition of a covered service shall be
restricted to the addition of a licensed professional staff member who can
perform a Medicaid covered service that is not currently being performed within
the FQHC, FQHC look-alike, or RHC by a licensed professional employed or
contracted by the facility.
(b) The
deletion of a covered service shall be restricted to the deletion of a licensed
professional staff member who can perform a Medicaid covered service that was
being performed within the FQHC, FQHC look-alike, or RHC by the licensed
professional staff member.
(5) A change in intensity shall:
(a) Include a material change;
(b) Increase or decrease the existing final
PPS rate by at least five (5) percent; and
(c) Last at least twelve (12)
months.
(6) The
department shall consider a change in scope request due to a statutory or
regulatory change that materially impacts the costs of visits at an FQHC, FQHC
look-alike, or RHC if:
(a) A government entity
imposes a mandatory minimum wage increase and the increase was:
1. Not included in the calculation of the
final PPS rate; or
2. Subsequently
included in the MEI applied yearly; or
(b)
1. A new
licensure requirement or modification of an existing requirement by the state
results in a change that affects all facilities within the class.
2. A provider shall document that an increase
or decrease in the cost of a visit occurred as a result of a licensure
requirement or policy modification.
(7) A requested change in scope shall:
(a) Increase or decrease the existing final
PPS rate by at least five (5) percent;
(b) Last at least twelve (12) months;
and
(c) Be submitted to the
department in writing.
(8)
(a) An
FQHC, FQHC look-alike, or RHC that requests a change in scope shall submit the
following documents to the department within six (6) months of the requested
effective date of a change in scope:
1. A
narrative describing the change in scope;
2. A completed MAP 100501, Prospective
Payment System Rate Adjustment, completed according to the Instructions for
Completing the MAP 100501 Form; and
3. A signed letter requesting the change in
scope.
(b) If the
department does not receive the documentation required regarding a change in
scope within six (6) months after the requested effective date of a change in
scope, the change in scope shall be denied.
(c)
1. The
department shall:
a. Review the documentation
listed in this subsection; and
b.
Notify the FQHC, FQHC look-alike, or RHC in writing of the:
(i) Approval or denial of the request for
change in scope within ninety (90) business days from the date the department
received the request; or
(ii) Need
for additional documentation from the FQHC, FQHC look-alike, or RHC to
establish an interim PPS rate associated with the change in scope.
2. If the department
requests additional documentation to calculate the interim PPS rate for a
change in scope, the FQHC, FQHC look-alike, or RHC shall:
a. Provide the additional documentation to
the department within thirty (30) days of the notification of need for
additional documentation; or
b.
Request an extension beyond thirty (30) days to provide the additional
documentation.
3.
a. The department shall grant no more than
one (1) extension.
b. An extension
shall not exceed thirty (30) days.
4. If the department approves the request for
a change in scope and receives all of the necessary documentation from an FQHC,
FQHC look-alike, or RHC within the timelines established in this section, the
department shall establish an interim PPS rate for the FQHC, FQHC look-alike,
or RHC based on the projected costs contained in the completed MAP 100501,
Prospective Payment System Rate Adjustment referenced in paragraph (a)2 of this
subsection.
(9)
(a) To
establish a PPS final rate resulting from a change in scope, the department
shall use a completed MAP 100501, Prospective Payment System Rate Adjustment
and Universal Cost Report submitted by the FQHC, FQHC look-alike, or RHC to the
department that contains twelve (12) months of cost data for the first full
fiscal year end after the effective date of the change in scope.
(b) Within six (6) months of the end of the
twelve (12) month cost data period referenced in paragraph (a) of this
subsection, the FQHC, FQHC look-alike, or RHC shall submit to the department
the completed MAP 100501, Prospective Payment System Rate Adjustment and
Universal Cost Report containing cost data corresponding to the twelve (12)
month cost data for the first full fiscal year end after the effective date of
the change in scope.
(c) The
department shall:
1. Review the completed MAP
100501, Prospective Payment System Rate Adjustment and Universal Cost Report
referenced in paragraph (a) of this subsection submitted by an FQHC, FQHC
look-alike, or RHC within ninety (90) business days of receiving the completed
MAP 100501, Prospective Payment System Rate Adjustment and Universal Cost
Report; and
2. Notify the FQHC,
FQHC look-alike, or RHC of the necessity of the FQHC, FQHC look-alike, or RHC
to submit additional documentation if necessary.
(d)
1. If
additional documentation is necessary to establish a PPS final rate, the FQHC,
FQHC look-alike, or RHC shall:
a. Provide the
additional documentation to the department within thirty (30) days of the
notification of need for additional documentation; or
b. Request an extension beyond thirty (30)
days to provide the additional documentation.
2. The department shall grant no more than
one (1) extension.
3. An extension
shall not exceed thirty (30) days.
(e)
1. If
the department requests additional documentation from an FQHC, FQHC look-alike,
or RHC but does not receive additional documentation or an extension request
within thirty (30) days, the department shall reimburse the FQHC, FQHC
look-alike, or RHC the FQHC's, FQHC look-alike's, or RHC's PPS final rate that
was in effect prior to the FQHC's, FQHC look-alike's, or RHC's request for a
change in scope until:
a. The additional
documentation has been received by the department; and
b. The department establishes a new final PPS
rate associated with the change in scope.
2. If an FQHC, FQHC look-alike, or RHC does
not submit a completed MAP 100501, Prospective Payment System Rate Adjustment
and Universal Cost Report to the department in accordance with paragraph (b) of
this subsection, the department shall:
a. Not
issue a new PPS final rate associated with the change in scope; and
b. Revert to paying the FQHC, FQHC
look-alike, or RHC the FQHC's, FQHC look-alike's, or RHC's PPS final rate that
was in effect prior to the FQHC, FQHC look-alike, or RHC requesting a change in
scope.
(f)
1. If any service included in a change in
scope is a service that can be identified on a paid claims listing, the
department shall review the FQHC's, FQHC look-alike's, or RHC's paid claims
Iisting for the period of time corresponding to the FQHC's, FQHC look-alike's,
or RHC's cost report period of time referenced in paragraphs (a) and (b) of
this subsection.
2. If an FQHC,
FQHC look-alike, or RHC has submitted all necessary information to the
department, within forty-five (45) days of reviewing the FQHC's, FQHC
look-alike's, or RHC's paid claims listing, the department shall:
a. Establish a final PPS rate, resulting from
the change in scope, for the FQHC, FQHC look-alike, or RHC; and
b. Notify the FQHC, FQHC look-alike, or RHC
in writing of the FQHC's, FQHC look-alike's, or RHC's:
(i) Final PPS rate; and
(ii) Appeal rights regarding the PPS final
rate.
3. To
allow adequate time for claim adjudication, a paid claims listing shall not be
requested until at least fourteen (14) months after the end of the FQHC's, FQHC
look-alike's, or RHC's cost report period associated with the change in
scope.
(g) If no service
included in a change in scope can be identified on a paid claims listing, and
the department has received a completed MAP 100501, Prospective Payment System
Rate Adjustment and Universal Cost Report referenced in paragraphs (a) and (b)
of this subsection, and no additional documentation is needed from the FQHC,
FQHC look-alike, or RHC, the department shall:
1. Not review a paid claims listing in
establishing a new PPS final rate for an FQHC, FQHC look-alike, or RHC
resulting from the change in scope; and
2. Establish a new PPS final rate for an
FQHC, FQHC look-alike, or RHC resulting from the change in scope within ninety
(90) days of receiving the completed MAP 100501, Prospective Payment System
Rate Adjustment and Universal Cost Report.
Section 11. Limitations and
Exclusions.
(1)
(a) Except for a case in which a recipient or
enrollee, subsequent to the first encounter at an FQHC, FQHC look-alike, or
RHC, suffers an illness or injury requiring additional diagnosis or treatment,
an encounter with more than one (1) health care provider or multiple encounters
with the same health care provider which take place on the same day and at a
single location shall constitute a single visit.
(b) The limit established in paragraph (a) of
this subsection shall:
1. Apply to an FQHC,
FQHC look-alike, or RHC; and
2. Not
apply to a PCC that is not an FQHC, FQHC look-alike, or RHC.
(2)
(a) Except as established in paragraph (b) of
this subsection, a vaccine available without charge to an FQHC, FQHC
look-alike, RHC, or PCC through the department's Vaccines for Children Program
and the administration of the vaccine shall not be reported as a cost to the
Medicaid Program.
(b) Adult flu
vaccine costs shall be allowed as Medicaid costs reported on a Universal Cost
Report.
(3) The
department shall not reimburse for services provided by an FQHC, FQHC
look-alike, PCC, or RHC to a recipient in a hospital unless the FQHC, FQHC
look-alike, PCC, or RHC has previously, any time prior to the hospital
admission, provided a service to the recipient at the FQHC's, FQHC
look-alike's, PCC's, or RHC's location.
Section 12. Out-of-State Providers.
(1) Except as established in subsection (2)
of this section, reimbursement to an out-of-state FQHC, FQHC look-alike, or RHC
shall be based on the rate on file with the FQHC's, FQHC look-alike's, or RHC's
state Medicaid agency.
(2) If an
out-of-state FQHC's, FQHC look-alike's, or RHC's reimbursement is an APM, the
department's reimbursement to the out-of-state FQHC, FQHC look-alike, or RHC
shall:
(a) Not be the APM the FQHC, FQHC
look-alike, or RHC receives in its state; and
(b) Be the final PPS rate that the FQHC, FQHC
look-alike, or RHC would receive in its state if it were not receiving an
APM.
Section
13. Federal Approval and Federal Financial Participation. The
department's reimbursement for services pursuant to this administrative
regulation shall be contingent upon:
(1)
Receipt of federal financial participation for the reimbursement; and
(2) Centers for Medicare and Medicaid
Services' approval for the reimbursement.
Section 14. Not Applicable to Managed Care
Organizations. A managed care organization shall not be required to reimburse
in accordance with this administrative regulation for a service covered
pursuant to:
(1)
(a)
907
KAR 1:054; or
(b)
907
KAR 1:082; and
(2) This administrative regulation.
Section 15. Appeal Rights. An
FQHC, FQHC look-alike, PCC, or RHC may appeal a department decision as to the
application of this administrative regulation as it impacts the facility's
reimbursement rate in accordance with
907
KAR 1:671.
Section
16. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) "MAP 100501, Prospective
Payment System Rate Adjustment", February 2013 edition;
(b) "Instructions for Completing the MAP
100501 Form", February 2013 edition;
(c) "Universal Cost Report", May 2015;
and
(d) "Universal Cost Report
Instructions", May 2015.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at the Department for
Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday
through Friday, 8 a.m. to 4:30 p.m.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
205.560(1),
216B.042,
42 U.S.C.
1396a