Section 29-4500. GENERAL PROVISIONS

 

4500.1Medicaid reimbursement for services furnished on or after January 1, 2001, by a Federally-Qualified Health Center (FQHC) shall be on a prospective payment system consistent with the requirements set forth in section 1902(aa) of the Social Security Act (42 U.S.C. 1396(aa)).

 

4500.2Each FQHC in existence during Fiscal Years (FYs) 1999 and 2000 shall be paid a prospective rate for each visit or encounter with a Medicaid recipient when a medical service or services are furnished. The prospective rate for services rendered beginning on or after January 1, 2001 through and including September 30, 2001, shall be calculated as follows:

 

(a)The sum of the FQHC's audited allowable costs for the FYs 1999 and 2000 shall be divided by the total number of patient visits in FYs 1999 and 2000.

 

(b)The amount established in subsection 4500.2(a) shall be adjusted to take into account any increase or decrease in the scope of such services furnished by the FQHC during FY 2001. Each FQHC shall report to the Medical Assistance Administration (MAA) any increase or decrease in the scope of services, including the starting date of the change. The amount of the adjustment shall be negotiated between the parties. The adjustment shall be implemented not later than 90 days after establishment of the negotiated rate.

 

(c)Allowable costs shall include reasonable costs that are incurred by a FQHC in furnishing Medicaid coverable services to Medicaid eligible patients, as determined by Medicare Reasonable Cost Principles set forth in 42 CFR 413.

 

4500.3For services furnished beginning FY 2002 and each fiscal year thereafter, a FQHC shall be reimbursed at a rate that is equal to the rate in effect for the previous fiscal year, increased by the percentage increase in the Medicare Economic Index, as defined in section 1842(i)(3) of the Social Security Act (42 U.S.C. 1395u(i)(3)) for primary care services, and adjusted to take into account any increase or decrease in the scope of services furnished by the FQHC during the fiscal year. Each FQHC shall report to the Medical Assistance Administration (MAA) any increase or decrease in the scope of services, including the starting date of the change. The amount of the adjustment for a increase or decrease in services shall be negotiated between the parties. The adjustment shall be implemented not later than 90 days after establishment of the negotiated rate.

 

4500.4In any case in which an entity first qualifies as a FQHC after FY 2000, the prospective rate for services furnished in the first year shall be equal to the average of the prospective rates paid to other FQHC's located in the same area with a similar caseload. For each fiscal year following the first year in which the entity first qualified as a FQHC, the prospective payment rate shall in computed in accordance with section 4500.3.

 

4500.5A FQHC that furnishes services to Medicaid recipients pursuant to a contract with a managed care entity, as defined in section 1932(a)(1)(B) of the Social Security Act (42 U.S.C. 1396u-2(a)(1)(B)), shall receive a supplemental payment if the FQHC's total reimbursement for services received from all managed care entities is less that the amount the FQHC would be entitled to receive pursuant to sections 4500.2 through 4500.4 of these rules. The amount of the supplemental payment shall equal the difference between the amount the FQHC is entitled to receive pursuant to sections 4500.2 through 4500.4 and the total amount received from all managed care entities for treating Medicaid managed care enrollees. The supplemental payment shall be paid quarterly.

 

4500.6Each FQHC shall submit to MAA on a quarterly basis, information regarding the amount of payments received from any managed care entity for treating Medicaid managed care enrollees.

 

source

Final Rulemaking published at 49 DCR 7724 (August 9, 2002).