Missouri Code of State Regulations
Title 13 - DEPARTMENT OF SOCIAL SERVICES
Division 70 - MO HealthNet Division
Chapter 94 - Rural Health Clinic Program
Section 13 CSR 70-94.010 - Independent Rural Health Clinic Program
Universal Citation: 13 MO Code of State Regs 70-94.010
Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This rule establishes the regulatory basis for Title XIX Medicaid payment for Independent Rural Health Clinic Services.
PURPOSE: This rule is being amended to reflect the current cost report form and related worksheets, provide an exemption to the cost report filing requirements, and to clarify documentation and record retention requirements, interim payments, and final settlements.
(1) Authority. This is the payment methodology used to reimburse providers in the MO HealthNet Independent Rural Health Clinic (RHC) program.
(2) Qualifications. For a clinic to qualify for participation in the MO HealthNet independent RHC program, the clinic must be an independent facility, which means that the clinic may not be part of a hospital. However, a clinic may be located in the same building as a hospital, as long as there is no administrative, organizational, financial, or other connection between the clinic and the hospital.
(3) General Principles.
(A) The MO HealthNet program shall reimburse
independent RHC providers based on the reasonable cost of RHC-covered services
related to the care of MO HealthNet participants (within program limitations)
less any copayment or other third party liability amounts which may be due from
MO HealthNet participants.
(B)
Reasonable costs shall be determined by the MO HealthNet Division based on desk
review of the applicable cost reports and shall be subject to adjustment based
on field audit. Reasonable costs shall not exceed the Medicare cost principles
set forth in 42 CFR part 413.
(4) Definitions. The following definitions shall apply for the purpose of this rule:
(A)
Desk review. The MO HealthNet Division's review of a provider's cost report
without on-site audit;
(B)
Division. Unless otherwise designated, division refers to the MO HealthNet
Division, the division of the Department of Social Services charged with
administration of the MO HealthNet program;
(C) Facility fiscal year. A facility's twelve
(12)-month fiscal reporting period;
(D) Generally accepted accounting principles
(GAAP). Accounting conventions, rules, and procedures necessary to describe
accepted accounting practice at a particular time promulgated by the
authoritative body establishing those principles;
(E) Medicaid cost report. The documents used
for the purpose of reporting the cost of rendering both covered and non-covered
services for the facility's fiscal year shall be the Medicare cost report forms
CMS-222-92 and all worksheets supplied by the division. If the Medicare
CMS-222-92 is superseded by an alternate Medicare developed cost reporting tool
during a facility's fiscal year, that tool must be used for the facility's
fiscal year; and
(F) Provider or
facility. An independent RHC with a valid MO HealthNet participation agreement
in effect with the Department of Social Services for the purpose of providing
RHC services to Title XIX eligible participants.
(5) Administrative Actions.
(A) Annual Cost Report.
1. Each independent RHC shall complete a
Medicaid cost report for the RHC's twelve- (12-) month fiscal period.
2. Each RHC is required to complete and
submit to the division an Annual Cost Report, including all worksheets,
attachments, schedules, and requests for additional information from the
division. The cost report shall be submitted on forms provided by the division
for that purpose.
A. An independent RHC may
be exempt from filing a Medicaid cost report if there is no MO HealthNet
reimbursement for the reporting period and the facility does not plan to bill
the MO HealthNet program for any claims for the 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 MHD for review and
approval:
(I) 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
(II) Worksheet S series of the
Medicare Cost Report. The applicable parts of the Worksheet S must be completed
and signed by an officer or administrator.
3. All cost reports shall be completed in
accordance with the requirements of this rule and the cost report instructions.
Financial reporting shall adhere to GAAP except as otherwise specifically
indicated in this rule.
4. The cost
report shall be submitted within five (5) calendar months after the close of
the reporting period. An extension may be granted upon the request of the RHC
and the approval of the division with an agreed upon date of completion. The
request must be received in writing by the division prior to the end of the
five (5) calendar-month period after the close of the reporting
period.
5. In a change of
ownership, the cost report for the closing period must be submitted within
forty-five (45) calendar days of the effective date of the change of ownership,
unless the change in ownership coincides with the seller's fiscal year end, in
which case the cost report must be submitted within five (5) months after the
close of the reporting period. No extensions in the submitting of cost reports
shall be granted when a change in ownership has occurred.
6. Cost reports 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.
7. Authenticated copies of agreements and
other significant documents related to the provider's operation and provision
of care to MO HealthNet participants must be attached to 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:
A. Audit, review, or
compilation statement prepared by an independent accountant, including
disclosure statements and management letter;
B. Contracts or agreements involving the
purchase of facilities or equipment during the past five (5) years if requested
by the division, the department, or its agents;
C. Contracts or agreements with owners or
related parties;
D. Contracts with
consultants;
E. Schedule detailing
all grants, gifts, and income from endowments, including amounts, restrictions,
and use;
F. Documentation of
expenditures, by line item, made under all restricted and unrestricted grants,
gifts, or endowments;
G. Statement
verifying the restrictions as specified by the donor, prior to donation, for
all restricted grants;
H. Leases or
rental agreements, or both, related to the activities of the
provider;
I. Management
contracts;
J. Provider of service
contracts; and
K. Working trial
balance actually used to prepare cost report with line number tracing notations
or similar identifications.
8. Under no circumstance will the division
accept amended cost reports for final settlement determination or adjustment
after the date of the division's notification of the final settlement
amount.
(B) Records.
1. Maintenance and availability of records.
A. A provider must keep records in accordance
with 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 independent RHCs 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 will 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 RHC does not maintain records that provide an adequate basis to determine
payments under MO HealthNet.
B. The
suspension or reduction continues until the RHC demonstrates to the division's
satisfaction that it does, and will continue to, maintain adequate
records.
(C)
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.
(D) 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.
(6) Nonallowable Costs. Cost not reasonably related to RHC services shall not be included in a provider's costs. Nonallowable cost areas include, but are not limited to, the following:
(A) Grants, gifts and income from endowments
will be deducted from total operating costs;
(B) Bad debts, charity, and courtesy
allowances;
(C) Return on equity
capital;
(D) Capital cost increases
due solely to changes in ownership;
(E) Amortization on intangible assets, such
as goodwill, leasehold rights, covenants, but excluding organizational
costs;
(F) Attorney fees related to
litigation involving state, local, or federal governmental entities and
attorney's fees which are not related to the provision of RHC services, such as
litigation related to disputes between or among owners, operators, or
administrators;
(G) Central office
or pooled costs not attributable to the efficient and economical operation of
the facility;
(H) Costs such as
legal fees, accounting and administration costs, travel costs, and the costs of
feasibility studies which are attributable to the negotiation or settlement of
the sale or purchase of any capital asset by acquisition or merger for which
any payment has been previously made under the program;
(I) Late charges and penalties;
(J) Finder's fees;
(K) Fund-raising expenses;
(L) Interest expense on intangible
assets;
(M) Religious items or
supplies or services of a primarily religious nature performed by priests,
rabbis, ministers, or other similar types of professionals. Costs associated
with portions of the physical plant used primarily for religious functions are
also nonallowable;
(N) Research
costs;
(O) Salaries, wages, or fees
paid to non-working officers, employees, or consultants;
(P) Value of services (imputed or actual)
rendered by nonpaid workers or volunteers; and
(Q) Costs of services performed in a
satellite clinic, which does not have a valid MO HealthNet participation
agreement with the Department of Social Services for the purpose of providing
RHC services to Title XlX-eligible participants.
(7) Interim Payments.
(A) Independent RHCs, unless otherwise
limited by regulation, shall be reimbursed on an interim basis by MO HealthNet
at the Medicare RHC rate. Interim payments shall be reduced by copayments and
other third party liabilities.
(B)
An independent RHC contracted with a MO HealthNet managed care health plan
shall be eligible for supplemental reimbursement up to its interim Medicare RHC
rate. The supplemental reimbursement shall make up the difference between what
the independent RHC would have been paid by the division based on the
independent RHC's Medicare rate and the total managed care health plan payments
made to the clinic during the reporting period for covered services rendered to
MO HealthNet 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 independent RHC but shall occur no less
frequently than every four (4) months. Supplemental reimbursement shall be
requested by the independent RHC on forms provided by the division.
Supplemental reimbursement for managed care charges shall be considered interim
reimbursement of the independent RHC's MO HealthNet costs.
(8) Final Settlement.
(A) Final Settlement Determination. The state
agency shall perform an annual desk review of the Medicaid cost reports for
each RHC's fiscal year and shall make the necessary payment adjustments (i.e.,
an additional payment or a recoupment), in order that the RHC's net
reimbursement shall equal reasonable costs as described in this section.
1. The total reimbursement amount due the RHC
for covered services furnished to MO HealthNet participants is based on the
allowable costs from the Medicaid cost report and is calculated as follows:
A. The average cost per visit is calculated
by dividing the total allowable cost incurred for the reporting period by total
visits for RHC services furnished during this period. The average cost per
visit is subject to tests of reasonableness which may be established in
accordance with this rule or incorporated in the Allowable Cost per visit as
determined on Worksheet C, Part I, line 9 of the cost report.
B. The total cost of RHC services furnished
to MO HealthNet participants is calculated by multiplying the allowable cost
per visit by the number of MO HealthNet visits for covered RHC
services.
2. The total
reimbursable cost is compared to the total interim payments made to the RHC
during the reporting period for MO HealthNet participants to determine the
amount of the final settlement owed to or due from the RHC. The total interim
payments include the amount paid by the division as determined from the
division's MMIS reports, the health plan payments as set forth in the Managed
Care contract, and third party liability payments.
3. The total reimbursement will be subject to
adjustment based on the results of a field audit which may be conducted by the
MO HealthNet Division or its contracted agents.
(B) Notification of Final Settlement.
1. The division will notify the RHC by letter
of a cost report final settlement after the division completes the desk review
of the cost report. The division's notification letter will include 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 RHC shall
indicate if the final settlement results in the following:
A. Underpayments. If the total reimbursement
due the RHC exceeds the interim payments made for the reporting period, the
division makes a lump-sum payment to the RHC to bring total payments into
agreement with total reimbursement due the RHC; and
B. Overpayments. If the total interim
payments made to a RHC for the reporting period exceed the total reimbursement
due the RHC for the period, the division arranges with the RHC for repayment of
the overpayment either by having it offset against the RHC's subsequent interim
payments, having the RHC repay by sending the division a payment, or a
combination of offset and payment.
2. The RHC 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 RHC believes
revisions to the division's desk review and 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
RHC 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 RHC
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.
(C) The annual desk review will be subject to
adjustment based on the results of a field audit which may be conducted by the
division or its contracted agents.
(9) Payment Assurance.
(A) The state will pay each RHC, which
furnishes the services in accordance with the requirements of the state plan,
the amount determined for services furnished by the RHC according to the
standards and methods set forth in the regulations implementing the RHC
Reimbursement Program.
(B) RHC
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, leasehold interests by whatever form for any RHC
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 RHC's current provider number and hold the entity with the
current provider number responsible for all MO HealthNet liabilities.
*Original authority: 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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