Missouri Code of State Regulations
Title 13 - DEPARTMENT OF SOCIAL SERVICES
Division 70 - MO HealthNet Division
Chapter 26 - Federally-Qualified Health Center Services
Section 13 CSR 70-26.010 - MO HealthNet Program Benefits for Federally-Qualified Health Center Services
Universal Citation: 13 MO Code of State Regs 70-26.010
Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This rule is being amended to reflect the current cost report form and related worksheet, provide an exemption to the cost report filing requirements, and to clarify documentation and record retention requirements, interim payments, and final settlements.
(1) Pursuant to the Omnibus Reconciliation Act of 1989, this regulation provides the payment methodology used to reimburse federally-qualified health centers (FQHCs) the allowable costs which are reasonable for the provision of FQHC-covered services to MO HealthNet participants.
(2) General Principles.
(A) The MO HealthNet
program shall reimburse FQHC providers based on the reasonable cost of
FQHC-covered services related to the care of MO HealthNet participants (within
program limitations) less any copayment or deductible amounts which may be due
from MO HealthNet participants effective for services on and after July 1,
1990.
(B) Reasonable costs shall be
determined by the MO HealthNet Division based on desk reviews of the applicable
cost reports and may be subject to adjustment based on field audits. Reasonable
costs shall not exceed the Medicare cost principles set forth in 42 CFR Part
413.
(C) Reasonable costs shall be
apportioned to the MO HealthNet program based on a ratio of covered charges for
MO HealthNet participants to total charges. Charges mean the regular rate for
various services which are established uniformly for both MO HealthNet
participants and other patients. MO HealthNet charges shall include MO
HealthNet managed care charges for covered services.
(D) An FQHC shall submit a MO HealthNet cost
report in the manner prescribed by the state MO HealthNet agency. The cost
report shall be submitted within five (5) months after the close of the FQHC's
reporting period. An extension may be granted upon the request of the FQHC and
the approval of the MO HealthNet Division with an agreed upon date of
completion. The request must be in writing and postmarked prior to the first
day of the sixth month following the FQHC's fiscal year end.
1. An FQHC may be exempt from filing a
Missouri Medicaid Title XIX Cost Report if MO HealthNet reimbursement is
twenty-five thousand dollars ($25,000) or less for the facility's reporting
period. The facility must submit a request to the division to waive the cost
report filing requirement within five (5) calendar months after the close of
the facility's reporting period. To request an exemption for the cost report
filing requirement, the following information must be submitted to the division
for review and approval:
A. A Low or No
Missouri Medicaid Utilization Waiver Request Form. This form may be obtained
from the division. The form must be fully completed and signed by an officer or
administrator; and
B. Worksheet S
series of the Medicare Cost Report. The Worksheet S must be completed and
signed by an officer or administrator.
(E) An FQHC cost report shall be submitted
and certified by an officer or administrator of the provider. Failure to file a
cost report within the prescribed period, except as expressly extended in
writing by the state agency, may result in the imposition of sanctions as
described in
13
CSR 70-3.030.
(F) Authenticated copies of agreements and
other significant documents related to the provider's operation and provision
of care to MO HealthNet participants must be included with the cost report at
the time of filing unless current and accurate copies have already been filed
with the division. Material which must be submitted includes, but is not
limited to, the following as applicable:
1.
Audited financial statements prepared by an independent accountant and
submitted to the MO HealthNet Division when available, including explanatory
notes, disclosure statements, and management letter;
2. Contracts or agreements involving the
purchase of facilities or equipment during the cost reporting period if
requested by the division, the department, or its agents;
3. Contracts or agreements with related
parties;
4. Schedule A detailing
all grants, gifts, donations, and income from endowments, including amounts,
restrictions, and use;
5.
Explanations of grants, gifts, donations, or endowments for which related
expenses have not been offset on Worksheet 1-B of the MO HealthNet Division
FQHC cost report. If subsequently requested by the division or its contracted
agents, documentation of related expenditures will also be submitted;
6. Leases or rental agreements, or both,
related to the activities of the provider;
7. Management contracts; and
8. Working trial balance actually used to
prepare the cost report with line number tracing notations or similar
identifications.
(G)
Records.
1. Maintenance and availability of
records.
A. A provider must keep records in
accordance with generally accepted accounting principles (GAAP) and maintain
sufficient internal control and documentation to satisfy audit requirements and
other requirements of this rule, including reasonable requests by the division
or its authorized agent for additional information.
B. Adequate documentation for all line items
on the cost report shall be maintained by a provider. Upon request, all
original documentation and records must be made available for review by the
division or its authorized agent at the same site at which the services were
provided. Copies of documentation and records shall be submitted to the
division or its authorized agent upon request.
C. Records of related organization, as
defined by
42 CFR
413.17, must be available upon
demand.
D. The division shall
retain all uniform cost reports submitted by the FQHCs for seven (7) years
after the final settlement relating to a cost report is finalized, including
the resolution of any subsequent appeals or other administrative actions
pertaining to the cost report.
E.
Each facility shall retain all financial information, data, and records
relating to the operation and reimbursement of the facility for seven (7) years
after the final settlement relating to a cost report is finalized, including
the resolution of any subsequent appeals or other administrative actions
pertaining to the cost report, and shall maintain those reports pursuant to the
record-keeping requirements of
42 CFR
413.20.
2. Adequacy of records.
A. The division may suspend reimbursement or
reduce payments to the appropriate fee schedule amounts if it determines that
the FQHC does not maintain records that provide an adequate basis to determine
payments under MO HealthNet.
B. A
suspension or reduction will continue until the FQHC demonstrates, to the
division's satisfaction, that it has an ongoing and current process in place to
ensure the maintenance of adequate records.
(H) Audits.
1. Any cost report submitted may be subject
to field audit by the division or its authorized agent.
2. A provider shall have available at the
field audit location one (1) or more knowledgeable persons authorized by the
provider and capable of explaining the provider's accounting and control system
and cost report preparation, including all attachments and
allocations.
3. If a provider
maintains any records or documentation at a location which is not the same as
the site where services were provided, the provider shall transfer the records
to the same facility at which the services were provided, or the provider must
reimburse the division or its authorized agent for reasonable travel costs
necessary to perform any part of the field audit in any off-site location, if
the location is acceptable to the division.
(I) Change in Provider Status. The next
payment due the provider after the division has received the notification of
the termination of participation in the MO HealthNet program or change of
ownership may be held by the division until the cost report is filed. Upon
receipt of a cost report prepared in accordance with this rule, the payments
that were withheld will be released.
(3) Nonallowable Costs. Any costs which exceed those determined in accordance with the Medicare cost reimbursement principles set forth in 42 CFR Part 413 are not allowable in the determination of a provider's total reimbursement. In addition, the following items specifically are excluded in the determination of a provider's total reimbursement:
(A) Grants, gifts, and income
from endowments will be deducted from total operating costs. Exceptions-
1. Grants awarded directly to an FQHC by
federal government agencies, such as the Health Resources and Services
Administration (HRSA) and Public Health Service;
2. Grants received by an FQHC from the
Missouri Primary Care Association (MPCA) in accordance with contractual
agreements between the MO HealthNet Division and MPCA;
3. Grants to FQHCs for covered services
provided to uninsured patients resulting in uninsured FQHC charges that are
included on Worksheet 2 of the MO HealthNet Division FQHC cost
report;
4. Grants or incentive
payments for the meaningful use of electronic health records (EHR) systems
which are either paid directly to FQHCs or assigned to FQHCs by their
performing providers; and
5.
Payments to FQHCs for participation in MO HealthNet Division Medical Home
initiatives.
(B) The
value of services provided by non-paid workers, including members of an
organization having an agreement to provide those services;
(C) Bad debts, charity, and courtesy
allowances;
(D) Return on equity
capital;
(E) Attorney fees related
to litigation involving state, local, or federal governmental entities, and
attorney fees which are not related to the provision of FQHC
services;
(F) Late charges and
penalties; and
(G) Research
costs.
(4) Interim Payments.
(A) FQHC services shall be
reimbursed on an interim basis up to ninety-two percent (92%) of charges for
covered services billed to the MO HealthNet program. Interim billings will be
processed in accordance with the claims processing procedures for the
applicable programs.
(B) An FQHC
contracted with a MO HealthNet managed care health plan shall be eligible for
supplemental reimbursement of up to ninety-two percent (92%) of managed care
charges. The supplemental reimbursement shall make up the difference between
what the FQHC would have been paid by the division based on the FQHC's managed
care charges for a reporting period and payments made to the FQHC during the
reporting period by the managed care health plans for covered services rendered
to managed care participants as set forth in the Managed Care contract. The
supplemental reimbursement shall occur pursuant to the schedule agreed to by
the division and the FQHC, but shall occur no less frequently than every four
(4) months. Supplemental reimbursement shall be requested by the FQHC on forms
provided by the division. Supplemental reimbursement for managed care charges
shall be considered interim reimbursement of the FQHC's MO HealthNet
costs.
(5) Final Settlement.
(A) An annual desk review will be
completed following submission of the FQHC's Medicaid cost report. The total
reimbursement amount due the FQHC for covered services furnished to MO
HealthNet participants is based on the allowable costs from the Medicaid cost
report. The MO HealthNet Division will make an additional payment to the FQHC
when the allowable reported MO HealthNet costs exceed interim payments made for
the cost-reporting period. The FQHC must reimburse the division when its
allowable reported MO HealthNet costs for the reporting period are less than
interim payments.
(B) The annual
desk review may be subject to adjustment based on the results of a field audit
which may be conducted by the division or its contracted agents.
(C) Cost reports must be fully, clearly, and
accurately completed. If any additional information, documentation, or
clarification requested by the division or its contracted agents is not
provided within fourteen (14) days of the date of receipt of the division's
request, payments may be withheld from the facility until the information is
submitted.
(D) Notification of
Final Settlement.
1. The division will notify
an FQHC by letter of a cost report final settlement after completion of the
division's cost report desk review. The division's notification letter will
include the desk review which details the adjustments the division made to the
facility's cost report, the calculation of the final settlement, and a
Settlement Agreement, which the facility will sign and return to the division
indicating it agrees with the final settlement calculation. The division's
written notice to the FQHC shall indicate if the final settlement results in
the following:
A. Underpayments. If the total
reimbursement due the FQHC exceeds the interim payments made for the reporting
period, the division makes a lump-sum payment to the FQHC to bring total
payments into agreement with total reimbursement due the FQHC; and
B. Overpayments. If the total interim
payments made to an FQHC for the reporting period exceed the total
reimbursement due the FQHC for the period, the division arranges with the FQHC
for repayment of the overpayment either by having it offset against the FQHC's
subsequent interim payments, having the FQHC repay by sending the division a
payment, or a combination of offset and payment.
2. The FQHC shall review the division's
notification letter and attachments and respond with a signed Settlement
Agreement indicating it has accepted the final settlement within fifteen (15)
calendar days of receiving the final settlement letter. If the FQHC believes
revisions to the division's desk review and/or final settlement are necessary
before it can accept the settlement, it must submit additional, amended, or
corrected data within the fifteen- (15-) day deadline. Data received from the
FQHC after the fifteen- (15-) day deadline may not be considered by the
division in determining if revisions to the final settlement are needed unless
the FQHC requests and receives an extension for submitting additional
information prior to the end of the fifteen- (15-) day deadline. If the
fifteen- (15-) day deadline passes without a response from the provider, the
division will proceed with processing the final settlement as set forth in the
division's notification letter, and the final settlement shall be deemed final.
The division may not accept an amended cost report or any other additional
information to revise the cost report or final settlement after the final
settlement is finalized.
(6) Payment Assurance.
(A) The state will pay each FQHC, which
furnishes the services in accordance with the requirements of the state plan,
the amount determined for services furnished by the FQHC according to the
standards and methods set forth in the regulations implementing the FQHC
Reimbursement Program.
(B) FQHC
services provided for those participants having available Medicare benefits
shall be reimbursed by MO HealthNet to the extent of the coinsurance and
deductible as imposed under Title XVIII.
(C) Where third-party payment is involved, MO
HealthNet will be the payer of last resort.
(D) Regardless of changes of ownership,
management, control, or leasehold interests by whatever form for any FQHC
previously certified for participation in the MO HealthNet program, the
division will continue to make all the Title XIX payments directly to the
entity with the FQHC's current provider number and hold the entity with the
current provider number responsible for all MO HealthNet liabilities.
*Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007 and 208.201, RSMo 1987, amended 2007.
Disclaimer: These regulations may not be the most recent version. Missouri 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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