Current through all regulations passed and filed through September 16, 2024
(A)
"Change in scope
of service" is an alteration in aspects of a prospective payment system (PPS)
service such as the procedures or items that are furnished, the frequency with
which they are furnished, and the type of personnel who furnish them.
(1)
A change in scope
of service is characterized by such factors as are specified in the following
non-exhaustive list:
(a)
The addition or discontinuation of a PPS
service;
(b)
The addition or discontinuation of a procedure or class
of procedures within a PPS service that involves the skills and training of a
higher-level practitioner, such as the expansion of PPS medical service to
include obstetrical-gynecological care provided by a physician or advanced
practice registered nurse or the provision of a full range of dental procedures
performed by a licensed dentist where previously only the services of a dental
hygienist had been available; or
(c)
A change in the
distribution of procedures within a PPS service that materially affects the
allocation of resources to that PPS service, such as a change in a medical
service "case mix" from eighty per cent family practice and twenty per cent
obstetrical-gynecological care to forty per cent family practice and sixty per
cent obstetrical-gynecological care.
(2)
The following
factors do not constitute a change in scope of service:
(a)
Wage
increases;
(b)
Changes in negotiated union contracts;
(c)
Renovations or
other capital expenditures;
(d)
An increase in
the number of lower-level staff members, such as a nurse practitioner at a site
that employs a family physician, a dental hygienist at a site that employs a
dentist, or a physical therapy assistant at a site that employs a physical
therapist;
(e)
An increase in the number of social service staff
members;
(f)
An increase in office space, such as the addition of
square footage at an FQHC or RHC, a satellite office, a school location, or a
mobile unit;
(g)
An increase in equipment or supplies;
(h)
An increase in
patient volume;
(i)
An increase in office hours;
(j)
The addition of
an adjunctive service such as a disease management program; or
(k)
Provision of a
PPS service by an FQHC or RHC practitioner at a related off-site
location.
(B)
"Cost report" is
a report of FQHC or RHC costs together with all schedules, attachments, and
supporting documentation, in accordance with the instructions specified for the
form.
(1)
For
purposes of establishing FQHC per-visit payment amounts, the Ohio department of
medicaid (ODM) uses form ODM 03421, "Federally Qualified Health Center Cost
Report" (rev. 7/2022).
(2)
For purposes of establishing RHC per-visit payment
amounts, ODM uses the appropriate medicare form, either CMS-222-17,
"Independent Rural Health Clinic Cost Report" (rev. 5/2018) or CMS 2552-10,
"Hospital and Hospital Health Care Complex Cost Report Certification and
Settlement Summary" (rev. 4/2020).
(C)
"Federally
qualified health center (FQHC)" is an entity that meets the definition of FQHC
set forth in
42
U.S.C. 1395x(aa)(4) (October
1, 2021).
(1)
"FQHC look-alike" is an FQHC that does not receive Public
Health Service Act (PHSA) grant funding.
(2)
"Government-operated FQHC" is an FQHC operated by a state,
county, or local government agency.
(D)
"Managed care
entity (MCE)" has the same meaning as in Chapter 5160-26 of the Administrative
Code.
(E)
"Medicaid wraparound payment" is an amount that is paid
by ODM to augment the payment made by an MCE to an FQHC or RHC. It equals any
positive difference obtained when the MCE payment is subtracted from the
per-visit payment amount (PVPA) for the visit.
(1)
For purposes of
determining timely filing in accordance with rule
5160-1-19 of the Administrative
Code, an MCE is treated as a third-party payer.
(2)
An FQHC or RHC
may submit a claim to ODM for medicaid wraparound payment before the later of
the following dates:
(a)
One hundred eighty days after the date on which the MCE
pays the original claim; or
(b)
Three hundred
sixty-five days after the date of service.
(3)
ODM will pay a
valid claim for medicaid wraparound payment within four months after
submission.
(F)
"Non-PPS service" is a service rendered at an FQHC or
RHC for which payment is generally made in accordance with rules in agency 5160
outside of Chapter 5160-28 of the Administrative Code.
(G)
"PPS" means
prospective payment system.
(H)
"Per-visit
payment amount (PVPA)" is the amount of medicaid payment established for a
visit for which payment is made under the PPS method described in rule
5160-28-05 of the Administrative
Code.
(I)
"PPS payment" is payment that is made under the PPS
method described in rule
5160-28-05 of the Administrative
Code.
(J)
"PPS service" is a service that is rendered during a
visit for which PPS payment is made.
(K)
"Related off-site
location" is a place other than an FQHC or RHC site at which a service is
performed, such as a school, a satellite office, a mobile unit, a long-term
care facility, an outpatient hospital setting used by an FQHC or RHC for
providing services to patients, or a practice location operated by an FQHC- or
RHC-contracted practitioner. For reporting purposes, a service rendered at a
related off-site location is attributed to the particular FQHC or RHC site
whose personnel provided the service.
(L)
"Related
organization" is an organization that is related to an FQHC or RHC by common
ownership or control.
(M)
"Rural health clinic (RHC)" is an entity that meets the
definition of RHC set forth in
42
U.S.C. 1395x(aa)(2) (October
1, 2021).
(N)
"Services and supplies furnished incident to" other
services has the same meaning as in chapter 13 of "Centers for Medicare and
Medicaid Services (CMS) Publication 100-02, Medicare Benefit Policy Manual"
(December 20, 2019), which is available at
http://www.cms.gov.
(O)
"Site," as used in this chapter of the Administrative
Code, is a separate and distinct location operated by an FQHC or RHC at which
healthcare services are rendered. An FQHC or RHC may have several
sites.
(P)
"Visit."
(1)
For PPS services other than transportation, a visit is
one face-to-face (person-to-person) encounter between a patient and a provider;
for medicaid payment purposes, a covered service rendered through telehealth by
an FQHC or RHC practitioner is a face-to-face encounter. For transportation
services, a visit is a one-way trip provided to or from a site where a covered
service is rendered on the same date.
(a)
Multiple
encounters with one health professional or encounters with multiple health
professionals constitute a single visit if all of the following conditions are
satisfied:
(i)
All encounters take place on the same day;
(ii)
All contact
involves a single PPS service; and
(iii)
The service
rendered is for a single purpose, illness, injury, condition, or
complaint.
(b)
Multiple encounters constitute separate visits if one
of the following conditions is satisfied:
(i)
The encounters
involve different PPS services; or
(ii)
The services
rendered are for different purposes, illnesses, injuries, conditions, or
complaints or for additional diagnosis and treatment.
(2)
A visit may take place at an FQHC or RHC site, in a
patient's home, at a related off-site location, or (for transportation) between
an FQHC or RHC site and a patient's home or a related off-site
location.
(3)
A visit may be conducted through telehealth if the
service is rendered in accordance with rule
5160-1-18 of the Administrative
Code.
(4)
No service provided to anyone other than a patient may
be claimed as a visit with that patient.
(5)
The following
activities are not visits:
(a)
Participation in a meeting or group session at which no
health service is provided, such as an orientation session for new patients, a
health presentation to a community group, or an informational presentation
about a program managed by an FQHC or RHC;
(b)
Provision of a
health service as part of a community service program such as a mass
immunization, a large group screening, or a health fair;
(c)
A service
rendered by a practitioner who is not employed by nor under contract with an
FQHC or RHC; and
(d)
A non-PPS service.
Replaces: 5160-28-01
