Current through Register Vol. 18, September 20, 2024
(1) An RHC or FQHC experiences a change in
scope of service if it has experienced a change in the type, intensity,
duration, or amount of an RHC or FQHC service. A change in scope of service may
result in an incremental change to the baseline PPS rate.
(2) An RHC or FQHC must apply to the
department if it experiences a change in scope of service, even if the change
in scope of service will not result in an incremental change to the baseline
PPS rate. An RHC or FQHC must follow the procedures in ARM 37.86.4409 and ARM
37.86.4410 to apply for a change in scope of service.
(3) A change in scope of service is limited
to the following circumstances, and an RHC or FQHC applying for a change in
scope of service must demonstrate at least one of the following:
(a) the addition of a new service not
incorporated in the baseline PPS rate or deletion of a service incorporated in
the baseline PPS rate;
(b) the
addition or deletion of a covered Medicaid RHC or FQHC service under the State
Plan;
(c) a change necessary to
maintain compliance with amended state or federal regulations or regulatory
requirements;
(d) a change in
service due to a change in applicable technology or medical practices utilized
by the RHC or FQHC not otherwise paid for through state or federal
funds;
(e) a change in the 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,
corresponding to a change in the services provided by the RHC or
FQHC;
(f) a change in operating
costs attributable to capital expenditures corresponding to a change in the
services provided by the RHC or FQHC; or
(g) a change in the provider mix, including,
but not limited to:
(i) a transition from
mid-level providers to physicians with a corresponding change in the services
provided by the RHC or FQHC; or
(ii) the addition or removal of specialty
providers with a corresponding change in the services provided by the RHC or
FQHC.
(4) An
RHC or FQHC must demonstrate how one or more of the circumstances in (3)
impacts services provided by the RHC or FQHC and must demonstrate an overall
change to the RHC or FQHC. For example, the RHC or FQHC may increase services
to a high need population; however, this increase may be offset by growth in
the number of lower intensity visits, thereby not warranting an incremental
change to the baseline PPS rate.
(5) The following circumstances alone do not
constitute a change in scope of service rate adjustment:
(a) a change in ownership, including
acquisition by another healthcare entity or RHC or FQHC;
(b) a change in the number of staff
furnishing an existing service;
(c)
an increase or decrease in administrative staff;
(d) a change in the number of
encounters;
(e) a change in the
cost of supplies for existing services;
(f) a change in salaries and benefits not
directly related to a change in scope of service;
(g) a change in patient type and/or volume
without a corresponding change in the services provided;
(h) capital expenditures for losses covered
by insurance;
(i) a change in
office location or office space;
(j) a change in office hours not directly
related to a change in the scope of service as described in (3);
(k) expansion or remodel not directly related
to a change in the scope of service as described in (3); or
(l) the addition of a new site or removal of
an existing site, which offers the same RHC or FQHC services.
(6) The circumstances in (5) may
be factors in demonstrating a change in scope of service as long as the RHC or
FQHC also demonstrates one or more of the circumstances in (3).
(7) RHCs or FQHCs that choose to participate
in contracted programs to provide services outside of the PPS rate must meet
the requirements and adhere to the rules outlined in the applicable contract.
(a) Contracts for services outside of RHC or
FQHC services will be reimbursed outside the PPS rate and such services will
not be included in calculation of the baseline PPS rate or in a request for
change in scope of service. Providers who chose to enter contracted programs
and meet all related requirements will receive a separate payment as
established in the Montana Medicaid State Plan or Centers for Medicare and
Medicaid Services approved waiver.
(b) If an RHC's or FQHC's existing baseline
PPS rate includes costs associated with contracted programs, the RHC or FQHC
must submit a change in scope of service to remove the contracted services from
the baseline PPS rate.
AUTH:
53-2-201,
53-6-113,
MCA; IMP:
53-2-201,
53-6-101,
53-6-111,
53-6-113,
MCA
