Current through Register Vol. 41, No. 3, September 23, 2024
A. Reimbursement
for tribal health clinics.
1. Services
provided by or through facilities of the Indian Health Services (IHS),
including at the option of the tribe, facilities operated by a tribe or tribal
organization, and funded by Title I or Title V of the Indian Self Determination
and Education Assistance Act of 1975 (25 USC §
5301 et seq.), also known as tribal 638
facilities, are paid at the applicable IHS U.S. Office of Management &
Budget (OMB) rate published annually in the Federal Register of Regulations by
IHS.
2. The most current published
IHS OMB outpatient per visit rate, also known as the outpatient all-inclusive
rate, is paid for up to five outpatient visits per beneficiary per calendar day
for professional services. An outpatient visit is defined as a face-to-face or
telemedicine contact between any health care professional at or through the IHS
facility authorized to provide services under the State Plan and a beneficiary
for the provision of Title XIX defined services, as documented in the
beneficiary's medical record.
3.
Included in the outpatient per visit rate are Medicaid-covered pharmaceuticals
or drugs, dental services, rehabilitative services, behavioral health services,
ancillary services, and emergency room services provided on-site, and medical
supplies incidental to the services provided to the beneficiary.
B. Virginia Medicaid reimburses
tribal 638 facilities in accordance with the most recently published annual
update of reimbursement rates for Indian Health Services, which is published in
the Federal Register of Regulations and on the Indian Health Services website
at https://www.ihs.gov on the page for
reimbursement rates. Encounters or visits are limited to health care
professionals as approved under the Virginia Medicaid State Plan. A tribal
health program selecting to enroll as a federally qualified health center
(FQHC) and agreeing to an alternate payment methodology (APM) will be paid
using the APM.
C. Alternative
payment methodology for tribal facilities recognized as FQHCs
1. Outpatient health programs or facilities
operated by a tribe or tribal organization that choose to be recognized as
FQHCs in accordance with § 1905 (I)(2)(B) of the Social Security Act and
the Indian Self-Determination and Education Assistance Act of 1975
(25 USC §
5301 et seq.) will be paid using an APM for
services, that is the published, all-inclusive rate (AIR). The APM/AIR rate is
paid for up to five face-to-face encounters or visits per recipient per
day.
2. The individual FQHC must
agree to receive the APM. If a tribal FQHC does not agree to accept the APM,
the Department of Medical Assistance Services shall seek accommodation with the
FQHC, which may include submitting a State Plan amendment to authorize an
alternative means of reimbursement for the FQHC.
Statutory Authority: § 32.1-325 of the Code of
Virginia;
42 USC §
1396 et
seq.
