Current through Register Vol. 24-18, September 15, 2024
(1) For services
provided during the period beginning January 1, 2001, and ending December 31,
2008, the medicaid agency's payment methodology for federally qualified health
centers (FQHC) was a prospective payment system (PPS) as authorized by
42 U.S.C.
1396a(bb)(2) and
(3).
(2) For services provided beginning January
1, 2009, FQHCs have the choice to be reimbursed under the PPS or to be
reimbursed under an alternative payment methodology (APM), as authorized by
42 U.S.C.
1396a(bb)(6). As required by
42 U.S.C.
1396a(bb)(6), payments made
under the APM are at least as much as payments that would have been made under
the PPS.
(3) The agency calculates
FQHC PPS encounter rates as follows:
(a)
Until an FQHC's first audited medicaid cost report is available, the agency
pays an average encounter rate of other similar FQHCs within the state,
otherwise known as an interim rate.
(b) Upon availability of the FQHC's first
audited medicaid cost report, the agency sets FQHC encounter rates at 100
percent of its total reasonable costs as defined in the cost report. FQHCs
receive this rate for the remainder of the calendar year during which the
audited cost report became available. The encounter rate is then adjusted each
January 1st by the percent change in the medicare economic index
(MEI).
(4) For FQHCs in
existence during calendar years 1999 and 2000, the agency sets encounter rates
prospectively using a weighted average of 100 percent of the FQHC's total
reasonable costs for calendar years 1999 and 2000 and adjusted for any increase
or decrease in the scope of services furnished during the calendar year 2001 to
establish a base encounter rate.
(a) The
agency adjusts PPS base encounter rates to account for an increase or decrease
in the scope of services provided during calendar year 2001 in accordance with
WAC
182-548-1500.
(b) The agency determines PPS base encounter
rates using audited cost reports, and each year's rate is weighted by the total
reported encounters. The agency does not apply a capped amount to these base
encounter rates. The formula used to calculate base encounter rates is as
follows:
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(c)
Beginning in calendar year 2002 and any year thereafter, encounter rates are
adjusted by the MEI for primary care services, and adjusted for any increase or
decrease in the FQHC's scope of services.
(5) The agency calculates the FQHC's APM
encounter rate for services provided during the period beginning January 1,
2009, and ending April 6, 2011, as follows:
(a) The APM utilizes the FQHC base encounter
rates, as described in subsection (4)(b) of this section.
(b) Base rates are adjusted to reflect any
approved changes in scope of service in calendar years 2002 through
2009.
(c) The adjusted base rates
are then increased by each annual percentage, from calendar years 2002 through
2009, of the IHS Global Insight index, also called the APM index. The result is
the year 2009 APM rate for each FQHC that chooses to be reimbursed under the
APM.
(6) This subsection
describes the encounter rates that the agency pays FQHCs for services provided
during the period beginning April 7, 2011, and ending June 30, 2011. On January
12, 2012, the federal Centers for Medicare and Medicaid Services (CMS) approved
a state plan amendment (SPA) containing the methodology outlined in this
section.
(a) During the period that CMS
approval of the SPA was pending, the agency continued to pay FQHCs at the
encounter rates described in subsection (5) of this section.
(b) Each FQHC has the choice of receiving
either its PPS rate, as determined under the method described in subsection (3)
of this section, or a rate determined under a revised APM, as described in (c)
of this subsection.
(c) The revised
APM uses each FQHC's PPS rate for the current calendar year, increased by five
percent.
(d) For all payments made
for services provided during the period beginning April 7, 2011, and ending
June 30, 2011, the agency recoups from FQHCs any amount in excess of the
encounter rate established in this section. This process is specified in
emergency rules that took effect on October 29, 2011, (WSR 11-22-047) and
February 25, 2012 (WSR 12-06-002).
(7) This subsection describes the encounter
rates that the agency pays FQHCs for services provided on and after July 1,
2011. On January 12, 2012, CMS approved a SPA containing the methodology
outlined in this section.
(a) Each FQHC has
the choice of receiving either its PPS rate as determined under the method
described in subsection (3) of this section, or a rate determined under a
revised APM, as described in (b) of this subsection.
(b) The revised APM, known as APM-3, is as
follows:
(i) For FQHCs that rebased their rate
effective January 1, 2010, the revised APM is their allowed cost per visit
during the cost report year increased by the cumulative percentage increase in
the MEI between the cost report year and January 1, 2011.
(ii) For FQHCs that did not rebase their rate
effective January 1, 2010, the revised APM is based on their PPS base rate from
2001 (or subsequent year for FQHCs receiving their initial FQHC designation
after 2002) increased by the cumulative percentage increase in the IHS Global
Insight index from the base year through calendar year 2008 and by the
cumulative percentage increase in the MEI from calendar years 2009 through
2011. The rates were increased by the MEI effective January 1, 2012, and are
increased by the MEI each January 1st thereafter.
(c) For all payments made for services
provided during the period beginning July 1, 2011, and ending January 11, 2012,
the agency recoups from FQHCs any amount paid in excess of the encounter rate
established in this section. This process is specified in emergency rules that
took effect on October 29, 2011, (WSR 11-22-047) and February 25, 2012 (WSR
12-06-022).
(d) For FQHCs that
choose to be paid under the revised APM, the agency periodically rebases the
encounter rates using the FQHC cost reports and other relevant data. Rebasing
is done only for FQHCs that are reimbursed under the APM.
(e) The agency ensures that the payments made
under the APM are at least equal to the payments that would be made under the
PPS.
(8) This subsection
describes the payment methodology that the agency uses to pay participating
FQHCs for services provided beginning July 1, 2017, and ending December 31,
2022.
(a) Each FQHC may receive payments under
the APM described in subsection (7) of this section, or receive payments under
the revised APM described in this subsection.
(b) The revised APM, known as APM-4, is as
follows:
(i) The revised APM establishes a
budget-neutral, baseline per member per month (PMPM) rate for each FQHC. The
PMPM rate accounts for enhancement payments in accordance with the definition
of enhancements in WAC
182-548-1100.
For the purposes of this section, "budget-neutral" means the cost of the
revised APM to the agency will not exceed what would have otherwise been spent
not including the revised APM on a per member per year basis.
(ii) The agency pays the FQHC a PMPM payment
each month for each managed care client assigned to them by an MCO.
(iii) The agency pays the FQHC a PMPM rate in
addition to the amounts the MCO pays the FQHC. The agency may prospectively
adjust the FQHC's PMPM rate for any of the following reasons:
(A) Quality and access metrics
performance.
(B) FQHC encounter
rate changes.
(iv) In
accordance with
42 U.S.C.
1396a(bb)(5)(A), the agency
performs an annual reconciliation.
(A) If the
FQHC was underpaid, the agency pays the difference, and the PMPM rate may be
subject to prospective adjustment under (b)(iii) of this subsection.
(B) If the FQHC was overpaid, the PMPM rate
may be subject to prospective adjustment under (b)(iii) of this
subsection.
Statutory Authority:
RCW
41.05.021. 12-16-060, §182-548-1400,
filed 7/30/12, effective 8/30/12. 11-14-075, recodified as §182-548-1400,
filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090, BIPA of 2000 Section 702, sections
201 and 209 of 2009-2011 budget bill, and
42 U.S.C.
1396 a(bb). 10-09-002, § 388-548-1400,
filed 4/7/10, effective 5/8/10.
