SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Effective Date of Rule: Thirty-one days after filing.
Purpose: The purpose of new chapter 388-549 WAC, Rural health clinics (RHCs), is to implement the federal payment methodology for RHCs under Section 702 of the Benefit Improvement and Protection Act (BIPA) of 2000. The act replaced cost-based reimbursement methodology with Medicaid RHC prospective payment system (PPS).
Statutory Authority for Adoption: RCW 74.08.090.
Other Authority: RCW 74.09.510, 74.09.522, 42 C.F.R. 405.2472, 42 C.F.R. 491.
Adopted under notice filed as WSR 08-01-090 on December 17, 2007.
A final cost-benefit analysis is available by contacting Kevin Collins, P.O. Box 45510, Olympia, WA 98504-5510, phone (360) 725-2104, fax (360) 586-9727, e-mail firstname.lastname@example.org.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 6, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 6, Amended 0, Repealed 0.
Date Adopted: February 7, 2008.
RURAL HEALTH CLINICS
"Base year" - The year that is used as the benchmark in measuring a clinic's total reasonable costs for establishing base encounter rates.
"Change in scope of service" - A change in the type, intensity, duration, or amount of service.
"Encounter" - A face-to-face visit between a client and a qualified rural health clinic (RHC) provider (e.g., a physician, physician's assistant, or advanced registered nurse practitioner) who exercises independent judgment when providing services that qualify for an encounter rate.
"Encounter rate" - A cost-based, facility-specific rate for covered RHC services, paid to a rural health clinic for each valid encounter it bills.
"Enhancements" (also called healthy options (HO) enhancement) - A monthly amount paid to RHCs for each client enrolled with a managed care organization (MCO). Plans may contract with RHCs to provide services under healthy options. RHCs receive enhancements from the department in addition to the negotiated payments they receive from the MCOs for services provided to enrollees.
"Fee-for-service" - A payment method the department uses to pay providers for covered medical services provided to medical assistance clients, except those services provided under the department's prepaid managed care organizations or those services that qualify for an encounter rate.
"Interim rate" - The rate established by the department to pay a rural health clinic for covered RHC services prior to the establishment of a prospective payment system (PPS) rate for that facility.
"Medicare cost report" - The cost report is a statement of costs and provider utilization that occurred during the time period covered by the cost report. RHCs must complete and submit a report annually to Medicare.
"Mobile unit" - The objects, equipment, and supplies necessary for provision of the services furnished directly by the RHC are housed in a mobile structure.
"Permanent unit" - The objects, equipment and supplies necessary for the provision of the services furnished directly by the clinic are housed in a permanent structure.
"Rural area" - An area that is not delineated as an urbanized area by the Bureau of the Consensus.
"Rural health clinic (RHC)" - A clinic, as defined in 42 CFR 405.2401(b), that is primarily engaged in providing RHC services and is:
• Located in a rural area designated as a shortage area as defined under 42 CFR 491.2;
• Certified by Medicare as a RHC in accordance with applicable federal requirements; and
• Not a rehabilitation agency or a facility primarily for the care and treatment of mental diseases.
"Rural health clinic (RHC) services" - Outpatient or ambulatory care of the nature typically provided in a physician's office or outpatient clinic and the like, including specified types of diagnostic examination, laboratory services, and emergency treatments. The specific list of services which must be made available by the clinic can be found under 42 CFR part 491.9.
(a) Receive RHC certification for participation in the Title XVIII (Medicare) program according to 42 CFR 491;
(b) Sign a core provider agreement;
(c) Comply with the clinical laboratory improvement amendments (CLIA) of 1988 testing for all laboratory sites per 42 CFR part 493; and
(d) Operate in accordance with applicable federal, state, and local laws.
(2) An RHC may be a permanent or mobile unit. If an entity owns clinics in multiple locations, each individual site must be certified by the department in order to receive reimbursement from the department as an RHC.
(3) The department uses one of two timeliness standards for determining the effective date of a Medicaid-certified RHC.
(a) The department uses Medicare's effective date if the RHC returns a properly completed core provider agreement and RHC enrollment packet within sixty days from the date of Medicare's letter notifying the clinic of the Medicare certification.
(b) The department uses the date the signed core provider agreement is received if the RHC returns the properly completed core provider agreement and RHC enrollment packet after sixty days of the date of Medicare's letter notifying the clinic of the Medicare certification.
(2) The department pays for RHC services when they are:
(a) Within the scope of an eligible client's medical assistance program. Refer to WAC 388-501-0060; and
(b) Medically necessary as defined in WAC 388-500-0005.
(3) RHC services may be provided by any of the following individuals in accordance with 42 CFR 405.2401:
(b) Physician assistants (PA);
(c) Nurse practitioners (NP);
(d) Nurse midwives or other specialized nurse practitioners;
(e) Certified nurse midwives;
(f) Registered nurses or licensed practical nurses; and
(g) Psychologists or clinical social workers.
(a) The department calculates the RHC's encounter rate for RHC core services as follows:
(i) Until the RHC's first audited Medicare cost report is available, the department pays an average encounter rate of other similar RHCs (such as hospital-based or free-standing) within the state, otherwise known as an interim rate.
(ii) Upon availability of the RHC's audited Medicare cost report, the department sets the clinic's encounter rate at one hundred percent of its costs as defined in the cost report. The RHC will receive this rate for the remainder of the calendar year during which the audited cost report became available. The encounter rate is then inflated each January 1 by the Medicare economic index (MEI) for primary services.
(2) For RHCs in existence during calendar years 1999 and 2000, the department sets the payment prospectively using a weighted average of one hundred percent of the clinic'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 department adjusts a PPS base encounter rate to account for an increase or decrease in the scope of services provided during calendar year 2001 in accordance with WAC 388-549-1500.
(b) The PPS base encounter rates are determined using Medicare's audited cost reports and each year's rate is weighted by the total reported encounters. The department does not apply a capped amount to these base encounter rates. The formula used to calculate the base encounter rate is as follows:
|Base Encounter Rate=||(1999 Rate X 1999 Encounters) + (2000 Rate X 2000 Encounters)|
|(1999 Encounters + 2000 Encounters)|
(3) The department pays for one encounter, per client, per day except in the following circumstances:
(a) The visits occur with different doctors with different specialties; or
(b) There are separate visits with unrelated diagnoses.
(4) RHC services and supplies incidental to the provider's services are included in the encounter rate payment.
(5) Services other than RHC services that are provided in an RHC are not included in the RHC encounter rate. Payments for nonRHC services provided in an RHC are made on a fee-for-service basis using the department's published fee schedules. NonRHC services are subject to the coverage guidelines and limitations listed in chapters 388-500 through 557 WAC.
(6) For clients enrolled with a managed care organization, covered RHC services are paid for by that plan.
(7) The department does not pay the encounter rate or the enhancements for clients in state-only programs. Services provided to clients in state-only programs are considered fee-for-service, regardless of the type of service performed.
(2) When the department determines that a change in scope of service has occurred after the base year, the department will adjust the RHC's perspective payment system (PPS) rate to reflect the change.
(3) RHCs must:
(a) Notify the department's RHC program manager in writing, at the address published in the department's rural health clinic billing instructions, of any changes in scope of service no later than sixty days after the effective date of the change; and
(b) Provide the department with all relevant and requested documentation pertaining to the change in scope of service.
(4) The department adjusts the PPS rate to reflect the change in scope of service using one or more of the following:
(a) A Medicaid comprehensive desk review of the RHC's cost report;
(b) Review of a Medicare audit of the RHC's cost report; or
(c) Other documentation relevant to the change in scope of service.
(5) The adjusted encounter rate will be effective on the date the change of scope of service is effective.