Current through September 24, 2024
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 (4
th) 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 (5
th) 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.
42 U.S. Code
§1396d; 42 C.F.R. Part 491; Miss. Code Ann. §§
43-13-117,
43-13-121;
SPA 2018-0012, SPA 2016-0013, SPA 15-003, SPA
2013-032.
