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 rural health clinics (RHC)
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, RHCs have the choice to be reimbursed under the PPS or 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
RHC PPS encounter rates for RHC core services as follows:
(a) Until an RHC submits its first audited or
as filed medicare cost report to the agency, the agency pays the RHC an average
encounter rate of other similar RHCs within the state, otherwise known as an
interim rate. Similar RHCs are defined as either all hospital based or all
free-standing RHCs.
(b) Upon the
RHC's request to the agency, which must include the submission of the RHC's
first as filed or audited medicare cost report, the agency calculates the RHC's
PPS rates for RHC core services. The agency sets each RHC's encounter rates by
dividing 100 percent of the RHC's costs divided by the total number of RHC
encounters reported in the submitted cost report. The encounter rate is
effective on the date the agency receives the submitted medicare cost report
from the RHC.
(c) RHCs receive this
rate for the remainder of the calendar year during which the submitted medicare
cost report became available to the agency. The agency then adjusts the
encounter rate each January 1st by the percent change in the medicare economic
index (MEI).
(4) For RHCs
in existence during calendar years 1999 and 2000, the agency sets the encounter
rates prospectively using a weighted average of 100 percent of the RHC'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
182-549-1500.
(b) The agency determines PPS base encounter
rates using medicare's 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 and adjusted for any increase or decrease in the RHC's
scope of services.
(5)
The agency calculated RHC's APM encounter rates for services provided during
the period beginning January 1, 2009, and ending April 6, 2011, as follows:
(a) The APM used the RHC base encounter rates
as described in subsection (4)(b) of this section.
(b) Base rates were increased by each annual
percentage, from calendar years 2002 through 2009, of the IHS Global Insight
index, also called the APM index.
(c) The result was the year 2009 APM rates
for each RHC that chose to be reimbursed under the APM.
(6) This subsection describes the encounter
rates that the agency paid RHCs 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 RHCs at the encounter rate
described in subsection (5) of this section.
(b) Each RHC had 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 used each RHC'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 recouped from RHCs any amount paid in excess of the
encounter rate established in this section. This process was 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
rate that the agency pays RHCs 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 RHC 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 RHCs 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 RHCs 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 RHCs receiving their initial RHC designation after
2002) increased by the cumulative percentage increase in the IHS Global Insight
index from the base year through calendar year 2008 and the cumulative increase
in the MEI from calendar years 2009 through 2011. The rates are increased by
the MEI effective January 1, 2012, and 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 recouped from RHCs any amount paid in excess of the
encounter rate established in this section. This process was specified in
emergency rules that took effect on October 29, 2011, (WSR 11-22-047) and
February 25, 2012 (WSR 12-06-002).
(d) For RHCs that choose to be paid under the
revised APM, the agency periodically rebases the encounter rates using the RHC
cost reports and other relevant data. Rebasing is done only for RHCs that are
reimbursed under the APM.
(e) The
agency makes sure 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 RHCs for services
provided beginning July 1, 2017, and ending December 31, 2022.
(a) Each RHC 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 RHC. 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 RHC a PMPM payment
each month for each managed care client assigned to them by an MCO.
(iii) The agency pays the RHC a PMPM payment
each month in addition to the amounts the MCO pays the RHC.
(iv) The agency may prospectively adjust the
RHC's PMPM rate for any of the following reasons:
(A) Quality and access metrics
performance.
(B) RHC encounter rate
changes.
(v) In
accordance with
42 U.S.C.
1396a(bb)(5)(A), the agency
performs an annual reconciliation.
(A) If the
RHC was underpaid, the agency pays the difference, and the PMPM rate may be
subject to prospective adjustment under (b)(iv) of this subsection.
(B) If the RHC was overpaid, the PMPM rate
may be subject to prospective adjustment under (b)(iv) of this
subsection.
Statutory Authority:
RCW
41.05.021. 12-16-060, §182-549-1400,
filed 7/30/12, effective 8/30/12. 11-14-075, recodified as §182-549-1400,
filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090,
74.09.510,
74.09.522,
42 U.S.C.
1396 a(bb),
42 C.F.R.
405.2472, and 42 C.F.R. 491. 10-09-030,
§ 388-549-1400, filed 4/13/10, effective 5/14/10. Statutory Authority:
RCW
74.08.090,
74.09.510,
74.09.522,
42 C.F.R.
405.2472, 42 C.F.R. 491. 08-05-011, §
388-549-1400, filed 2/7/08, effective
3/9/08.
