Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 34 - RURAL HEALTH CLINICS (RHC's)
Section 471-34-005 - Prospective Payment System

Universal Citation: 471 NE Admin Rules and Regs ch 34 ยง 005

Current through March 20, 2024

005.01 Payment for Services Provided by Provider-Based Rural Health Clinics Associated with Hospitals Having 50 Beds or Greater

The Department will compute the Prospective Payment System (PPS) base rate as follows:

1. Combine reasonable costs from the RHC fiscal year 1999 and 2000 cost reports; then

2. Divide the cost by the combined Total Adjusted Visits from the two fiscal year cost reports (Form CMS- 222-92 Worksheet C, Part 1, Line 6; or Form CMS- 2552-96 Worksheet M-3, Line 6).

Effective October 1, 2001, the Department will update the PPS base rate annually using the Medicare Economic Index (MEI).

005.02 Payment for Services Provided by Provider-Based RHCs Associated with Hospitals Having Less Than 50 Beds

NMAP pays for RHC services provided by provider-based clinics that are associated with hospitals of less than 50 beds at the lower of cost or charges as established by Medicare.

005.03 Payment for Services Provided by Independent Rural Health Clinics (IRHCs)

The Department will compute the PPS base rate for IRHCs as follows:

1. Combine reasonable costs from the RHC fiscal year 1999 and 2000 cost reports; then

2. Divide the cost by the combined total adjusted visits from the two fiscal year cost reports.

Effective October 1, 2001, the Department will update the PPS base rate annually using the Medicare Economic Index (MEI).

005.04 Rates for New RHCs

The Department will establish rates for a new RHC entering the program after 1999 as follows:

1. For the initial year, the interim rate will be an average of the PPS rate of all RHCs in Nebraska. The interim rate will be retroactively settled based on the RHC's initial cost report.

2. The RHC's individual PPS base rate will be computed using its initial cost report.

3. Once the PPS base rate has been established, it will be updated annually based on the Medicare Economic Index (MEI).

005.05 RHC Managed Care Payment

RHCs that provide services under a contract with a Medicaid managed care entity (MCE) will receive quarterly state supplemental payments for the cost of furnishing such services that are an estimate of the difference between the payment the RHC receives from the MCE(s) and the payments the RHC would have received under the PPS methodology or payments as established under Section 34-005.02 for those RHC receiving payment as a provider based RHC associated with hospitals having less than 50 beds.

34-005.05A At the end of each RHC fiscal year, for each Independent RHC and Provider based RHC associated with hospital of 50 or more beds the Department will compare:
1. The total amount of supplemental and MCE payments received by the RHC; to

2. The amount that the actual number of visits provided under the RHC's contract with the MCE(s) would have yielded under the PPS methodology.

The Department will pay the RHC the difference between item 1 and item 2 if the PPS amount exceeds the total amount of supplement and MCE payments. The RHC must refund the difference between item 1 and item 2 if the PPS payment is less than the total amount of the supplemental and MCE payments.

34-005.05B At the end of each RHC fiscal year for Provider based RHC associated with hospital having less than 50 beds, the Department will compare:
1. The total amount of the supplemental and the MCE(S) payments received by the RHC

2. The amount that the clinic would have received as payment under section 34-005.02.

The Department will pay the RHC the difference between item 1 and 2 if the actual amount exceeds the total amount of supplement and MCE payments. The RHC must refund the difference between item 1 and item 2 if the actual payment is less than the supplemental and MCE payments received by the RHC.

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