(Medicare Benefit Policy Manual)

Certain services are not considered RHC or FQHC services either because they 1) are not  included in the RHC or FQHC benefit, or 2) are not a Medicare benefit. Non- RHC/FQHC  services include, but are not limited to:   Medicare excluded services  - Includes routine physical checkups, dental care, hearing tests, routine eye exams, etc.  For additional information, see Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage, at http://www.cms.gov/Regulations- a nd-Guidance/Guidance/Manuals/downloads/bp102c16.pdf   Technical component of an RHC or FQHC service - Includes diagnostic te sts such as x - rays, electrocardiograms (EKGs), and other tests authorized by Medicare statute or the NCD process.  These services may  be billed  separately  to the A/B MAC  by the facility).  (The professional component is an RHC or FQHC service if performed by an RHC or FQHC  practitioner  or furnished incident to an RHC or  FQHC  visit).   Laboratory services  - Although RHCs and FQHCs are required to furnish certain laboratory services (for RHCs see section 1861(aa)(2)(G) of the Act, and for FQHCs see section 330(b)(1)(A)(i)(II) of the PHS Act), laboratory services are not within the scope of the RHC or FQHC benefit.  When clinics and centers separately bill laboratory  services, the cost of associated space, equipment, supplies, facility overhead and personnel f or these services must be adjusted out of the RHC or FQHC cost report. This  does not include venipuncture, which is included in the AIR when furnished in an RHC by an RHC practitioner or furnished incident to an RHC service, and it is included in the per-diem payment when furnished in an FQHC by an FQHC practitioner or furnished incident to an FQHC service.   Durable medical equipment - Includes crutches, hospital beds, and wheelchairs used in the patients place of  residence, whether rented or  purchased.  Ambulance services  - The ambulance transport benefit under Medicare Part B covers a medically necessary transport of a beneficiary by ambulance to the nearest appropriate  facility that can treat the patient's condition, and any other methods of transportation are contraindicated.  See https://www.cms.gov/Regulations- and- Guidance/Guidance/Manuals/downloads/bp102c10.pdf for additional information on covered  ambulance services.  Prosthetic devices  - Prosthetic devices are included in the definition of medical and other health services in section 1861(s)(8) of the Act and are defined as devices (other than  dental)  which  replace all or  part of an  internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of such devices,  and including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens.  Other examples of  prostheti c devices include cardiac pacemakers, cochlear implants, electrical continence  aids,  electrical nerve stimulators, and  tracheostomy  speaking  valves.   Body  Braces   Includes  leg, arm,  back,  and neck  braces  and their  replacements.   Practitioner services at certain other Medicare facility   Includes services furnished to inpatients or outpatients in a hospital (including CAHs), ambulatory surgical center, Medicare Comprehensive Outpatient Rehabilitation Facility, etc., or other facility whose  requirements pre clude RHC or FQHC services.  (NOTE: Covered services provided to a Medicare beneficiary by an RHC or FQHC practitioner in a SNF may be an RHC or  FQHC  service.)   Telehealth  distant- site services  - See section  200 of  this chapter  for additional information  on telehealth  services in RHCs  and FQHCs.   Hospice Services  (with the exception of hospice attending physician services)   See section 210 of this chapter for additional information on hospice  services  in RHCs and FQHCs.   Group Services   Includes group or mass  information programs, health  education  classes,  group therapy, or group education activities, including media productions and publications. 70 - RHC and FQHC Payment  (Rev. 252, Issued: 12-07-18, Effective: 01-01-19, Implementation: 01- 02 -19)  RHCs and FQHCs must submit claims for RHC or FQHC services under the RHC or FQHC payment methodologies and are not authorized to submit claims under the Physician Fee Schedule (PFS) for RHC or FQHC services.  Newly certified RHCs or FQHCs should work with their  A/B MAC to ensure that all claims filed for RHC or FQHC services are paid as RHC or FQHC claims as of the date of their certification.   70.1 - RHC Payment  (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Medicare pays 80 percent o f the RHC AIR, subject to a payment limit, for medically -necessary medical, and qualified preventive, face- to - face (one-on- one) visits with an RHC practitioner (as defined in section 30) for RHC services (as defined in section 50.1), unless otherwise noted.  The rate is subject to a payment limit, except for RHCs that have an exception to the payment limit (see section 70.2).  An interim rate for newly certified RHCs is established based on the RHCs anticipated average cost for direct and supporting services.  At the end of the reporting period, the A/B MAC determines the total payment due and reconciles payments made during the period with the total payments due. In general, the AIR for an RHC is calculated by the A/B MAC by dividing total allowable costs by the total number of visits for all patients.  Productivity, payment limits, and other factors are also considered in the calculation.  Allowable costs must be reasonable and necessary and include practitioner compensation, overhead, equipment, space, supplies, personnel, and other costs incident to the delivery of RHC services. Services furnished incident to an RHC professional service are included in the AIR and are not billed as a separate visit.  The professional component of a procedure is usually a covered service, but is not a stand-alone billable visit.  The costs of covered services provided incident to a billable visit may be included on the RHC cost report.  To receive payment for qualified services, HCPCS coding is required on all claims.  70.2 - RHC Payment Limit  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  Prior to April 1, 2021, t he RHC payment limit was set by Congress in 1988 and was  adjusted annually based on     the Medicare Economic Index (MEI).  The payment limit was  released annually via Recurring  Update Notifications.   Prior to April 1, 2021, a provider-based RHC that is an integral and subordinate part of a hospital (including a CAH), as described in regulations at 42 CFR 413.65, could receive an exception to the per- visit payment limit if:    the hospital had fewer  than  50 beds as  determined  at 42 CFR 412.105(b) ; or   the hospital's average daily patient census count of those beds described in 42 CFR 412.105(b) did not exceed 40 and the hospital meets both of the following conditions:  o it was  a sole community hospital as determined  in accordance with  42 CFR  412.92 or an essential access community hospital as determined in accordance with 42 CFR 412.109(a), and  o it was  located in a level 9 or level 10 Rural-Urban Commuting Area (RUCA).  (For additional information on RUCAs, see http://depts.washington.edu/uwruca/.  The exception to the payment limit applied only during the time that the RHC met  the  requirements  for the exception.  70.2.1  Payment Limits Applicable to Independent RHCs, Provider-Based RHCs in a Hospital with 50 or More Beds, and New RHCs  (Rev. 11803; Issued: 01-26-23; Effective: 01 -01-23; Implementation: 02-27-23)  Beginning April 1, 2021, independent RHCs, provider-based RHCs in a hospital with 50 or more beds, and RHCs enrolled under Medicare on or after January 1, 2021 will receive a prescribed national statutory pay ment limit per visit increase over an 8 -year period for each year from 2021 through 2028.    The national statutory payment limit for RHCs over the 8-year period is as follows:    In 2021, after March 31, at $100 per visit;    In 2022, at $113 per visit;     In 2023, at $126 per visit;    In 2024, at $139 per visit;    In 2025, at $152 per visit;    In 2026, at $165 per visit;    In 2027, at $178 per visit; and    In 2028, at $190 per visit.   Beginning in 2029 and each year thereafter the limit established for the previous year is increased by the percentage increase in MEI applicable to primary care services furnished as of the first day of such year.  We note that new RHCs are those that have submitted an application and are enrolled under Medicare on or after January 1, 2021.  70.2.2  Payment Limits Applicable to Provider -Based RHCs in a Hospital with Less than 50 Beds  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  Beginning April 1, 2021, provider- based RHCs that meet a specified criteria are entitled to special payment rules that establish a payment limit based on the provider-based RHCs per visit payment amount (or AIR) instead of the national statutory payment limit.  For purposes of this section of the manual, we use the term specified interchangeably with the term grandfathered since those RHCs that meet the specified criteria are considered to be grandfathered into the establishment of their payment limi t per visit.   The specified criteria that an RHC must meet in order to be eligible for the special payment rules are as follows:   As of December 31, 2020, was in a hospital with less than 50 beds (not taking into account any increase in the number of beds pursuant to a waiver during the Public Health Emergency (PHE) for COVID -19); and one of the following circumstances: o As of December 31, 2020, was enrolled in Medicare (including temporary enrollment during the PHE for COVID -19); or  o Submitted an application for enrollment in Medicare (or a request for temporary enrollment during the PHE for COVID-19) that was received not later than December 31, 2020.   Medicare Administrative Contractors (MACs) will calculate the payment limit per visit for speci fied provider-based RHCs (that is, grandfathered RHCs) as discussed in sections 70.2.2.1 and 70.2.2.2 below.   A grandfathered provider-based RHC will lose this designation if the hospital does not continue to have less than 50 beds. If this occurs, the provider-based RHC will be subject to the statutory payment limit per visit applicable for such year for RHCs discussed in section 70.2.1 of this manual.  70.2.2.1  Determining Payment Limits for Specified Provider -Based RHCs with an AIR Established for RHC Services Furnished in 2020  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  Beginning April 1, 2021, specified provider-based RHCs that had a per visit payment amount (that is, AIR) established for services furnished in 2020, the payment limit per visit shall be set at an amount equal to the greater of :  1. the per visit payment amount applicable to such RHC for services furnished in 2020, increased by the percentage increase in the MEI applicable to primary care services furnished as of the first day of 2021; or  2. the national statutory payment limit for RHCs  per visit  (see section 70.2.1 of this chapter).