Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-549 - Rural health clinics
Section 182-549-1500 - Rural health clinics-Change in scope of service rate adjustment
Universal Citation: WA Admin Code 182-549-1500
Current through Register Vol. 24-18, September 15, 2024
In accordance with 42 U.S.C. 1396a(bb)(3)(B), the agency adjusts its payment rate to a rural health clinic (RHC) to take into account any increase or decrease in the scope of the RHC's services. The procedures and requirements for any such rate adjustment are described below.
(1) Triggering events.
(a) An RHC may file a change in scope of
services rate adjustment application with the agency on its own initiative only
when the RHC satisfies the criteria described in (a)(i), (ii), and (iii) of
this subsection.
(i) When the cost to the RHC
of providing covered health care services to eligible clients has increased or
decreased due to one or more of the following triggering events:
(A) A change in the type of health care
services the RHC provides;
(B) A
change in the intensity of health care services the RHC provides. Intensity
means the total quantity of labor and materials consumed by an individual
client during an average encounter has increased;
(C) A change in the duration of health care
services the RHC provides. Duration means the length of an average encounter
has increased;
(D) A change in the
amount of health care services the RHC provides in an average
encounter;
(E) Any change
comparable to (a)(i)(A) through (D) of this subsection in which the type,
intensity, duration or amount of services has decreased and the cost of an
average encounter has decreased.
(ii) The cost change equals or exceeds:
(A) An increase of one and three-quarters
percent in the prospective payment system (PPS) rate per encounter over one
year as measured by comparing the cost per encounter to the then current PPS
rate;
(B) A decrease of two and
one-half percent in the PPS rate per encounter over one year as measured by
comparing the cost per encounter to the then current PPS rate; or
(C) A cumulative increase or decrease of five
percent in the PPS rate per encounter as compared to the current year's cost
per encounter.
(iii) The
costs reported to the agency to support the proposed change in scope rate
adjustment are reasonable under state and federal law.
(b) At any time, the agency may instruct the
RHC to file a medicare cost report with a position statement indicating whether
the RHC asserts that its PPS rate should be increased or decreased due to a
change in the scope of services.
(i) The RHC
files a completed cost report and position statement no later than 90 calendar
days after receiving the instruction from the agency to file an
application;
(ii) The agency
reviews the RHC's cost report and position statement under the same criteria
listed above for an application for a change in scope adjustment;
(iii) The agency will not request more than
one change in scope in a calendar year.
(2) Filing requirements.
(a) The RHC may apply for a prospective
change in scope of service rate adjustment, a retrospective change in scope of
service rate adjustment, or both, in a single application.
(b) Unless instructed to file an application
by the agency, the RHC may file no more than one change in scope of service
application per calendar year; however, more than one type of change in scope
may be included in a single application.
(c) The RHC files for a change in scope of
service rate adjustment based on the following deadlines, whichever is later:
(i) Ninety calendar days after the end of the
RHC's fiscal year, demonstrating that the change in scope occurred.
(ii) Ninety calendar days after the RHC
learned the cost threshold in subsection (1)(a)(ii) of this section was
met.
(d) Prospective
change in scope.
(i) A prospective change in
scope of service rate adjustment application states each triggering event
listed in subsection (1)(a)(i) of this section that supports the RHC's
application.
(ii) A prospective
change in scope of service rate adjustment application must be based on one of
the following:
(A) A change the RHC plans to
implement in the future. The RHC submits 12 months of projected data and costs
sufficient to establish an interim rate; or
(B) A change with less than 12 months of
experience to support the change reflected in the medicare cost report. The RHC
submits a combination of historical data and projected costs sufficient to
establish an interim rate.
(iii) The interim rate adjustment goes into
effect after the change takes effect.
(iv) The interim rate is subject to the post
change in scope review and rate adjustment process defined in subsection (5) of
this section.
(v) If the change in
scope occurs less than 90 calendar days after the RHC submitted a complete
application to the agency, the interim rate takes effect no later than 90
calendar days after the complete application was submitted to the
agency.
(vi) If the change in scope
occurs more than 90 calendar days but less than 180 calendar days after the RHC
submitted a complete application to the agency, the interim rate takes effect
when the change in scope occurs.
(vii) If the RHC fails to implement a change
in service identified in its prospective change in scope of service rate
adjustment application within 180 calendar days, the application is void and
the RHC may resubmit the application to the agency, in such a circumstance, (b)
of this subsection does not apply.
(viii) If the change in scope is based on a
triggering event that already occurred but is supported by less than 12 months
of data in the filed cost report, the interim rate takes effect on the date the
RHC submitted the completed application to the agency.
(e) Retrospective change in scope.
(i) A retrospective change in scope of
service rate adjustment application states each triggering event listed in
subsection (1)(a)(i) of this section that supports its application and include
12 months of data documenting the cost change caused by the triggering event. A
retrospective change in scope is a change that took place in the past and the
RHC is seeking to adjust its rate based on that change.
(ii) If approved, a retrospective rate
adjustment takes effect on the date the RHC submitted a complete application to
the agency, as determined by the agency.
(3) Supporting documentation.
(a) To apply for a change in scope of service
rate adjustment, the RHC submits the following supporting documentation to the
agency in electronic format by email to fqhcrhc@hca.wa.gov:
(i) A narrative description of the proposed
change in scope;
(ii) A description
of each cost center on the cost report that was or will be affected by the
change in scope;
(iii) The RHC's
most recent audited financial statements, if audit is required by federal
law;
(iv) The implementation date
for the proposed change in scope; and
(v) Any additional documentation requested by
the agency.
(b) A
prospective change in scope of service rate adjustment application must also
include the projected medicare cost report with supplemental schedules
necessary to identify the medicaid cost per visit for the 12-month period
following implementation of the change in scope.
(c) A retrospective change in scope of
service rate adjustment application must also include the medicare cost report
with supplemental schedules necessary to identify the medicaid cost per visit
and encounter data for one of the following:
(i) The 12-month period following the
implementation of the triggering event; or
(ii) The fiscal year following implementation
of the proposed change in scope.
(4) Review of the application.
(a) Application processing.
(i) The agency reviews the application for
completeness, accuracy, and compliance with program rules.
(ii) Within 60 days of receiving the
application, the agency notifies the RHC of any deficient documentation or
requests any additional information that is necessary to process the
application. If the RHC does not provide the agency with the documentation or
information requested within 30 calendar days of the request, the agency may
deny the application.
(iii) Within
90 calendar days of receiving a complete application, including any additional
documentation or information that the agency might request, the agency sends
the RHC:
(A) A decision stating whether it
will implement a PPS rate change; and
(B) A rate-setting statement if the rate
change is implemented.
(iv) The RHC may appeal the decision on the
application as provided for in WAC 182-549-1650.
(b) Determining rate for change in scope.
(i) The agency sets an interim rate for
prospective changes in scope by adjusting the RHC's existing rate by the
projected average cost per encounter of any approved change. The agency reviews
the costs to determine if they are reasonable, and sets a new interim rate
based on the determined cost per encounter.
(ii) The agency sets an adjusted encounter
rate for retrospective changes in scope by adjusting the RHC's existing rate by
the documented average cost per encounter of the approved change. The agency
reviews the costs to determine whether they are reasonable, and sets a new rate
based on the determined cost per encounter.
(c) If the RHC is paid under an alternative
payment methodology (APM), any change in scope of service rate adjustment
approved by the agency modifies the PPS rate in addition to the APM.
(d) The agency may delegate the duties
related to application processing and rate setting to a third party. The agency
retains final responsibility and authority for making decisions related to
changes in scope.
(5) Post change in scope of services rate adjustment review.
(a) If the approved change in scope rate
adjustment was based on a retrospective change in scope application (i.e.,
based on a year or more of actual encounter data), the agency may conduct a
post change in scope rate adjustment review.
(b) If the approved change in scope rate
adjustment was based on a prospective change in scope application (i.e., less
than a full year of actual encounter data), the RHC submits the following
information to the agency within 18 months of the effective date of the rate
adjustment:
(i) Medicare cost report with
supplemental schedules necessary to identify the medicaid cost per visit and
encounter data for 12 consecutive months of experience following implementation
of the change in scope;
(ii) A
narrative description of the request;
(iii) A description of each cost center on
the cost report that was affected by the change in scope;
(iv) The RHC's most recent audited financial
statements, if audit is required by applicable law; and
(v) Any additional documentation requested by
the agency.
(c) The
agency conducts the post change in scope review within 90 calendar days of
receiving the cost report and encounter data from the RHC.
(d) If necessary, the agency adjusts the
encounter rate within 90 calendar days to make sure that the rate reflects the
reasonable cost of the change in scope of services.
(e) A rate adjustment based on a post change
in scope review takes effect on the date the agency issues its adjustment. The
new rate is prospective.
(f) If the
RHC fails to submit the post change in scope cost report or related encounter
data, the agency provides written notice to the clinic within 30 calendar
days.
(g) If the RHC fails to
submit required documentation within five months of the notice identified in
(f) of this subsection, the agency may reinstate the prechange in scope
encounter rate going forward from the date the interim rate was established.
The agency may recoup any overpayment to the RHC.
11-14-075, recodified as §182-549-1500, 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, § 388-549-1500, 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, § 388-549-1500, filed 2/7/08, effective 3/9/08.
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