(Medicare Benefit Policy Manual)

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).  For subsequent years, the specified provider-based RHCs payment limit per visit shall be set at an amount equal to the gr eater of :  1. the payment limit per visit established for the previous year, increased by the percentage increase in the MEI applicable to primary care services furnished as of the first day of such subsequent year; or  2. the national statutory payment limit for RHCs (see section 70.2.1 of this chapter).  Note: For purposes of establishing the payment limit effective April 1, 2021 for specified provider-based RHCs defined in section 1833(f)(3)(A)(i)(I) of the Act, that is, had an AIR established for services f urnished in 2020, MACs shall use the cost report ending in 2020 that reports costs for 12 -consecutive months. If the RHC does not have a 12- consecutive month cost report ending in 2020, the MACs shall use the next available 12-consecutive month cost report that reports costs for RHC services furnished in 2020. MACs should not combine cost report data to equal a 12-consecutive month cost report.  70.2.2.2   Determining Payment Limits for Specified Provider -Based RHCs that did not have 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 did not have a per visit payment amount (that is, AIR) established for services furnished in 2020, the payment limit per visit shall be at an amount equal to the greater of :   1. the per visit payment amount applicable to the provider-based RHC for services furnished in 2021; or 2. the national statutory payment limit for RHCs (see section 70.2.1 of this chapter).  For subsequent years, the provider-based RHCs payment limit per visit shall be set at an amount equal to the greater of :  1. the payment limit per visit established for the previous year, increased by the percentage increase in MEI applicable to primary care services furnished as of the first day of such subsequent year; or  2. the national statutory payment limit for RHCs (see sec tion 70.2.1 of this chapter). Note: For purposes of establishing the payment limit effective April 1, 2021 for specified provider-based RHCs defined in section 1833(f)(3)(A)(i)(II) of the Act (that is, those that did not have an AIR established for services furnished in 2020), the MACs shall use the cost report ending in 2021 that reports costs for 12 consecutive months. If the RHC does not have a 12-consecutive month cost report ending in 2021, the MACs shall use the next most -recent final settled cost rep ort that reports cost for 12- consecutive months. MACs should not combine cost report data to equal a 12-consecutive month cost report.  70.3 - FQHC PPS Payment Rate and Adjustments (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Medicare pays 80 percent of the lesser of the FQHCs charge or the FQHC PPS payment rate for the specific payment code, unless otherwise noted.  Except for grandfathered tribal FQHCs, the FQHC PPS payment rate reflects a base rate that is the same for all FQHCs, a geographic adjustment based on the location where services are furnished, and other applicable adjustments as described below.  The 2015 and 2016 FQHC PPS base rates were updated by the MEI.  Beginning in 2017, the FQHC PPS rate is updated annuall y by the FQHC market basket.  To receive payment for qualified services, HCPCS coding is required on all claims. Geographic Adjustment:   The PPS base rate is adjusted for each FQHC based on its location by the FQHC Geographic Adjustment Factor (FQHC GAF).  The PPS payment rate is the PPS base rate multiplied by the FQHC GAF for the location where the service is furnished.  Since the FQHC GAF is based on where the services are furnished, the FQHC payment rate may differ among FQHC sites within the same organ ization.  FQHC GAFs are updated periodically and can be found at: https://www.cms.gov/Center/Provider- T ype/Federally -Qualified -Health -Centers -FQHC -Center.html .  New Patient Adjustment:  The PPS payment rate is adjusted by a factor of 1.3416 when an FQHC furnishes care to a patient who is new to the FQHC.  A new patient is someone who has not received any Medicare- covered professional health service ( medical or mental health) from any site within the FQHC organization, or from any practitioner within the FQHC organization, within the past 3 years from the date of service. IPPE and AWV Adjustment:   The PPS payment rate is adjusted by a factor of 1.3416 when an FQHC furnishes an IPPE or an AWV to a Medicare beneficiary.  NOTE:   These adjustments do not apply to grandfathered tribal FQHCs.  70.4 - FQHC Payment Codes  (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  FQHCs set their own  charges for services they provide and determine which services are included in the bundle of services associated with each FQHC G code based on a typical bundle of services that they would furnish per diem to a Medicare beneficiary.  The FQHC should maint ain records of the services included in each FQHC G code and the charges associated with the service at the time the service was furnished.  Each FQHC decides what documentation is appropriate to record the services included in each G -code pursuant to its own determination.  Charges must be reasonable and uniform for all patients, regardless of insurance status.  G code services and charges can be changed by the FQHC, but must be the same for all patients and cannot be changed retrospectively.  FQHCs must in clude one or more of the FQHC payment codes listed below on claims to receive payment for services furnished:  1. G0466  FQHC visit, new patient:  A medically -necessary medical, or a qualified preventive health, face- to-face encounter (one- on-one) between a new patient (as defined in section 70.3), and an FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare -covered services that would be furnished per diem to a patient receiving an FQHC visit.  2. G0467  FQHC visit, established patient:  A medically -necessary medical, or a qualifying preventive health, face -to-face encounter (one- on-one) between an established patient and an FQHC practitioner during which time one or more FQHC services are rende red and includes a typical bundle of Medicare -covered services that would be furnished per diem to a patient receiving an FQHC visit.  3. G0468  FQHC visit, IPPE or AWV:  An FQHC visit that includes an IPPE or AWV and includes a typical bundle of Medicare -covered services that would be furnished per diem to a patient receiving an IPPE or AWV. 4. G0469 FQHC visit, mental health, new patient:  A medically -necessary, face -to-face mental health encounter (one -on-one) between a new patient (as defined in sectio n 70.3), and an FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare -covered services that would be furnished per diem to a patient receiving a mental health visit.  5. G0470  FQHC visit, mental health, established patient:  A medically -necessary, face- to-face mental health encounter (one- on-one) between an established patient and an FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medi care- covered services that would be furnished per diem to a patient receiving a mental health visit.  80 - RHC and FQHC Cost Reports (Rev. 220, Issued: 01- 15-16, Effective: 02- 01-16, Implementation: 02- 01-16)  80.1 - RHC and FQHC Cost Report Requirements (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)  RHCs are required to file a cost report annually in order to determine their payment rate  and reconcile interim payments, including  adjustments  for GME  payments, bad  debt, and  influenza , pneumococcal and COVID -19 vaccines , and covered monoclonal antibody products used as pre -exposure prophylaxis prevention of COVID -19  and their administration.  If in its initial reporting  period, the RHC submits a budget that estimates the allowa ble costs and number of visits  expected during the reporting period. The A/B MAC calculates an interim rate based on  a percentage of the per-visit limit,  which  is then  adjusted  when the  cost report  is filed.   FQHCs are required to file a cost report annually and are paid for the costs of GME, bad debt, and influenza , pneumococcal  and COVID-19  vaccines , and covered monoclonal antibody products used as pre-exposure prophylaxis prevention of COVID-19 and their administration through the cost report. All FQHCs,  including an FQHC  that does not have GME  costs,  bad debt, or costs  associated with  influenza , pneumococcal and COVID-19 vaccines , or covered monoclonal antibody products used as pre- exposure prophylaxis prevention of COVID-19 and their  administration,  must file  a cost report. The RHC and FQHC cost reports were updated to reflect costs related to COVID-19 shots and COVID-19 monoclonal antibody products and their administration.   Note : Until the end of the calendar year in which the Emergency Use Authorization (EUA) declaration for drugs and biological products with respect to COVID-19 ends, CMS covers and pays for these infusions or injections the same way it covers and pays for COVID-19 vaccines when furnished consistent with the EUA. That is, for RHCs and FQHCs COVID-19 monoclonal antibody products (when purchased from the manufacturer) and their administration are paid at 100 percent of reasonable cost through the cost report. Effective January 1 of the year following the year in which the EUA declaration ends, CMS will cover and pay for monoclonal antibody products used for the treatment or for post- exposure prophylaxis of COVID-19 in the same way we pay for other Part B drugs and biological products.  For RHCs, payment is through the All-Inclusive Rate and for FQHCs payment is through the FQHC Prospective Payment System.  RHCs  and FQHCs  must maintain  and provide adequate cost data based  on financial  and statistical records that can be verified  by qualified  auditors. RHCs and FQHCs are allowed to claim bad debts in accordance with 42 CFR 413.89 . RHCs may claim unpaid coinsurance and deductible, and FQHCs may claim unpaid coinsurance. RHCs and FQHCs that claim bad debt must establish that reasonable efforts  were made to collect these amounts Coinsurance or deductibles that are waived, either  due to a statutory  waiver  or a sliding  fee scale, ma y not be claimed.