Current through Register Vol. 35, No. 18, September 24, 2024
All services provided by the FQHC must be furnished in
accordance with applicable federal, state, and local laws and regulations and
must be furnished within the limitations applicable to medicaid-covered
benefits. If not specified in this section, MAD adopts definitions of coverage
delineated in the FQHC sections of medicare statutes. "Other ambulatory
services" offered by the FQHC are subject to the same medicaid limitations,
utilization review requirements, and coverage restrictions that exist for other
providers rendering the delineated service.
A. Physician services:
(1) Physician services are professional
services that are performed by a physician, including psychiatrists, employed
by or under contract with the FQHC.
(2) Services and supplies incident to a
physician's professional service are covered if the service or supply meets
delineated requirements. Services and supplies include the professional
component of radiology services, laboratory services performed by the FQHC and
specimen collection for laboratory services furnished by an off-site
laboratory. To meet the definition of "incident to" a professional service, the
service and supplies must be:
(a) of a type
commonly furnished in a physician's office; within the meaning of the Code of
Federal Regulations (CFR) page 128 Section 405.2413 (a) (1) 10-01-98
edition;
(b) of a type commonly
rendered either without charge or included in the FQHC encounter
rate;
(c) furnished as an
incidental, although integral, part of a physician's professional
service;
(d) furnished under
direct, personal supervision of a physician; and
(e) in the case of a service, furnished by a
member of the FQHC's health care staff who is an employee of the FQHC or under
contract with the FQHC.
(3) Inpatient hospital visits are those
services furnished to an individual as a "patient" of the FQHC. Therefore, FQHC
services furnished off-site (including those furnished to a person who is an
inpatient of a hospital or nursing facility) will be considered FQHC services
only if the physician's agreement with the FQHC requires that they seek
compensation from the FQHC. (Section 4704 c of OBRA '90, amended Section 1905
1,2.) (HCFA Letter #91-18 dated March 1991.)
B. Mid-level practitioners: Services
furnished by a nurse practitioner, physician assistant, nurse midwife, or
specialized nurse practitioner are covered as an FQHC core service if the
service is:
(1) furnished by a nurse
practitioner, physician assistant, nurse midwife, or specialized nurse
practitioner who is employed by or under contract with the FQHC;
(2) furnished in accordance with FQHC
policies and individual treatment plans developed by FQHC personnel for a given
client;
(3) a type which the nurse
practitioner, physician assistant, nurse midwife or specialized nurse
practitioner who furnished the service is permitted by licensure or
certification;
(4) furnished under
the supervision of a physician, if required by New Mexico law.
(a) The physician supervision requirement is
met if the conditions specified in Section 491.8 (b) of the Social Security Act
and any pertinent requirements specified under New Mexico law are satisfied.
(b) To be covered, the services
provided by mid-level practitioners must comply with New Mexico law.
(c) Services and supplies are covered as
incident to the provision of services by a mid-level practitioner if the
requirements specified in Paragraph (2) of Subsection A of
8.310.4.12 NMAC are met.
(d) The direct personal supervision
requirement for mid-level practitioners is met if the mid-level practitioner is
permitted to supervise under the written policies governing the FQHC and as
defined under New Mexico law.
C. Outpatient mental health services:
Diagnosis and treatment of mental illness are covered services when the service
is provided by an individual licensed as a physician by the board of medical
examiners or board of osteopathy and who is board-eligible or board-certified
in psychiatry, a licensed clinical psychologist (Ph.D., Psy. D., or Ed. D.), a
licensed independent social worker (LISW), a licensed professional clinical
mental health counselor (LPCC), a licensed marriage and family therapist
(LMFT), or a clinical nurse specialist certified in psychiatric nursing (CNP)
who is employed by or under contract with the FQHC. An FQHC is reimbursed for
services furnished by licensed master's level social workers, licensed
psychology associates and master's level licensed counselors who are graduates
of an accredited program when the services are furnished under the direction
and supervision as addressed under Subsection C of 8.310.8.10 NMAC.
D. Visiting nurse services: Visiting nurse
services are covered if the FQHC is located in an area identified by the
secretary of health and human services as having a shortage of home health
agencies. No additional certification is required beyond the FQHC
certification. To be covered, visiting nurse services must be:
(1) rendered to clients who meet criteria for
home health services;
(2) furnished
by a registered nurse, licensed practical nurse, or licensed vocational nurse
who is employed by or under contract with the FQHC; and
(3) furnished under a written plan of
treatment that is established and signed by a supervising physician; the plan
may also be established by a nurse practitioner, physician assistant, nurse
midwife, or specialized nurse practitioner employed by or under contract with
the FQHC; the plan must be reviewed every 60 days by the supervising physician
and revised as the client's condition warrants;
(4) visiting nurse services do not include
household and housekeeping services or other services that constitute custodial
care.
E. Preventive
services:
(1) Preventive primary services that
an FQHC may provide are those services as defined in the
42 CFR
405.2448 and include:
(a) medical social services;
(b) nutritional assessment and
referral;
(c) individual preventive
health education;
(d) well-child
care, including periodic screening, to include children's eye and ear
examinations;
(e) prenatal and
postpartum care;
(f) immunizations
for children and adults, including tetanus-diphtheria booster and influenza
vaccine;
(g) family planning
services;
(h) physical examinations
targeted to risk, to include blood pressure measurement, weight, and client
history;
(i) visual acuity
screening;
(j) hearing
screening;
(k) cholesterol
screening;
(l) stool testing for
occult blood;
(m) dipstick
urinalyses;
(n) risk assessment and
initial counseling regarding risks;
(o) tuberculosis testing for high risk
clients;
(p) preventive dental
services;
(q) for women only: PAP
smears; clinical breast exams; referral for mammography; and thyroid function
tests.
(2) Documentation
of any service provided by the FQHC must be available in the client's
record.
(3) Preventive primary
services do not include eyeglasses, hearing aids, group or mass information
programs, health education classes, or group education activities, including
media productions and publications.
F. Pharmacy services: Pharmacy services and
medical supplies are covered services and are included as an allowable cost if
dispensed from an FQHC. An FQHC encounter for the provision of medical,
behavioral health, and dental services includes related pharmacy services. The
FQHC shall not bill a separate encounter for the provision of pharmacy
services. To dispense medications, the FQHC must be licensed as a licensed drug
clinic under the Pharmacy Practice Act.
G. Dental services:
See 8.310.7 NMAC, Dental Services, for
benefit coverage and service limitation. Dentists and dental hygienists
providing services for an FQHC must provide services within the scope of their
license as defined in the New Mexico Dental Health Care Act.
H. Case management: Targeted case management
services are covered services and are subject to the same requirements that
apply to providers who furnish case management services. 8.326.2 NMAC through
8.326.8 NMAC (MAD-771 - MAD-779).
