Source: http://placer.networkofcare.org/UC/Legislate/BillText.aspx?id=15205&bill=AB%20770
Timestamp: 2019-09-19 06:36:48
Document Index: 113683945

Matched Legal Cases: ['art 413', 'art 75', 'art 75', 'art 413', 'art 75', 'art 413', 'art 75', 'art 413', 'art 75', 'art 413', 'art 75', 'art 1']

(Coauthors: Assembly Members Cunningham, LimÃ³n, and Robert Rivas)
AB 770, as introduced, Eduardo Garcia. Medi-Cal: federally qualified health clinics: rural health clinics.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that federally qualified health center (FQHC) services and rural health clinic (RHC) services, as defined, are covered benefits under the Medi-Cal program, to be reimbursed, in accordance with Medicare reasonable cost principles, and to the extent that federal financial participation is obtained, to providers on a per-visit basis that is unique to each facility. Existing law prescribes the reimbursement rate methodology for both establishing and adjusting the per-visit rate. Under existing law, if an FQHC or RHC is partially reimbursed by a 3rd-party payer, such as a managed care entity, the department is required to reimburse the FQHC or RHC for the difference between its per-visit rate programs on a contract-by-contract basis, as specified. Existing law authorizes an FQHC or RHC to apply for an adjustment to its rate based on a change in the scope of service that it provides within 150 days following the beginning of the FQHC's or RHC's fiscal year, and authorizes an FQHC or RHC to appeal a grievance of complaint concerning various matters, including ratesetting and scope of service change, as described. Existing law provides that the department's implementation of FQHC and RHC services is subject to federal approval and the availability of federal financial participation.
This bill would require the methodology of the adjusted per-visit rate to exclude, among other things, a per-visit payment limitation, and a provider productivity standard. The bill would authorize an FQHC or RHC to apply for a rate adjustment for the adoption, implementation, or upgrade of a certified electronic health record system as a change in the scope of service. The bill would clarify, among other terms, the meaning of "scope of service." The bill would expand the meaning of "visit" to include FQHC and RHC services rendered outside of the facility location, as specified. The bill would modify how the department reimburses an FQHC or RHC that is partially reimbursed by a 3rd-party payer, as described. The bill would repeal the provisions authorizing an FQHC or RHC to apply for an adjustment to its rate based on a change in the scope of service that it provides within 150 days following the beginning of the FQHC's or RHC's fiscal year, and would instead extend the time frame for an FQHC or RHC to file a scope of service rate change to any time during the fiscal year, as specified. The bill would additionally authorize an FQHC or RHC to elect to appeal specified matters either through the departmental appeal process or by filing a petition for a writ of mandate. The bill would require the department to ensure that department staff conducting audits related to FQHC and RHC services receive appropriate training on federal and state laws governing these facilities, as specified. The bill would incorporate federal standards related to FQHCs and RHCs, and would make various conforming and technical changes.
(c) Federally qualified health center services and rural health clinic services FQHC and RHC services shall be reimbursed on a per-visit basis in accordance with the definition of "visit" set forth in subdivision (g).
(d) Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) FQHC and RHC per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e) (1) An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of service provided by the FQHC or RHC. Rate changes based on a change in the scope of services service provided by an FQHC or RHC shall be evaluated in accordance with Medicare federal reasonable cost reimbursement principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 and Part 75 (commencing with Section 400) of Title 45 of the Code of Federal Regulations, or its any successor. To the extent there is a conflict between the federal reasonable cost principles, the terms of Part 75 (commencing with Section 400) of Title 45 shall control. To the extent required under federal law, the adjusted per-visit rate shall include direct costs, administrative costs, and costs related to FQHC and RHC services rendered outside of the respective facility, consistent with guidance issued by the federal Centers for Medicare and Medicaid Services and the federal Health Resources and Services Administration. The methodology of the adjusted per-visit rate shall exclude a per-visit payment limitation, provider productivity standard, or any other method that applies cost limitations in the calculation of the per-visit rate that are not based on the reasonable cost of the FQHC or RHC as determined under applicable federal reasonable cost principles.
(B) A change in service due to amended regulatory requirements or rules. rules, or a change related to a Medi-Cal managed care plan contracting under this chapter or Chapter 8 (commencing with Section 14200) that either directly or indirectly impacts and FQHC or RHC.
(D) A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic. FQHC or RHC.
(G) Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic. practices, including the adoption, implementation, or upgrade of a certified electronic health record system, at the FQHC or RHC.
(I) Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA). Administration, including FQHC or RHC services rendered outside of the respective facility.
(3) A No change in costs is not, shall, in and of itself, a scope-of-service be considered a scope of service change, unless all of the following apply:
(A) The increase or decrease in cost cost, including administrative costs, is attributable to an a change in the FQHC or RHC scope of service service, such as an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable. these services. For purposes of this section, "scope of service" means the type, intensity, duration, or amount of services during an average FQHC or RHC visit as defined in subdivision (g). "Change in the scope of service" and "scope of service change" means any change, such as an increase or decrease, in the type, intensity, duration, or amount of services, or any combination thereof taking place in an average FQHC or RHC visit as defined in subdivision (g).
(B) The cost is allowable under Medicare federal reasonable cost principles set forth in Part 413 (commencing with Section 413) of Subchapter B of Chapter 4 of Title 42 and Part 75 (commencing with Section 400) of Title 45 of the Code of Federal Regulations, or its successor.
(C)The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination thereof.
(C) The net change in the FQHC's or RHC's rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs an FQHC and RHC that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service scope of service change. "Net change" means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4) An FQHC or RHC may submit requests for scope-of-service changes a scope of service change once per fiscal year, only within 90 days and at any time following the beginning of the FQHC's or RHC's fiscal year. Any approved increase or decrease in the provider's rate shall be retroactive to the beginning of the FQHC's or RHC's fiscal year in which the request is submitted.
(5) An FQHC or RHC shall submit a scope-of-service scope of service rate change request within 90 days of the beginning of any at any time during the FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHC's or RHC's prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services scope of service provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope of service rate change request within 90 days of the beginning of the at any time during the following fiscal year. year that the FQHC or RHC discontinued providing the service. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, "significantly lower" means an average per-visit rate decrease in excess of 2.5 percent.
(6) Notwithstanding paragraph (4), if the approved scope-of-service scope of service change or changes were initially implemented on or after the first day of an FQHC's or RHC's fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service scope of service change, the adjusted reimbursement rate for that scope-of-service scope of service change shall be made retroactive to the date the scope-of-service scope of service change was initially implemented. Scope-of-service changes A scope of service change under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHC's or RHC's fiscal year ending in 2003.
(f) (1) An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). (m). These supplemental payments shall be determined separately from the scope-of-service scope of service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHC's or RHC's PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.
(g) (1) An FQHC or RHC "visit" means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. For purposes of this section, "physician" shall be interpreted in a manner consistent with the federal Centers for Medicare and Medicaid Services' Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plan's definition of an FQHC or RHC visit. FQHC and RHC services rendered to a Medi-Cal beneficiary at a premise such as a temporary shelter, a beneficiary's residence, a location of another provider, or any location other than the location identified on the primary care clinic license or in the provider master file, shall be billed by the FQHC or RHC and reimbursed at the contracted rate when either of the following apply:
(A) The location where the services are provided is approved by the federal Health Resources and Services Administration as part of the FQHC's or RHC's application for its grant under Section 330 of the Public Health Service Act.
(h) (1) If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include programs, and managed care financial incentive payments that are required by federal law to shall be excluded from the calculation. Financial incentive payments shall include, but are not limited to, monetary payments to an FQHC or RHC by a third-party payor for superior contract performance, such as improving health outcomes, reducing overall cost of care, or increasing the quality of care.
(ii) The FQHC or RHC submits the change in scope of service request within 90 days after the at any time during the FQHC's or RHC's first full fiscal year.
(ii) Rate changes based on a change in scope of service request shall be evaluated in accordance with Medicare federal reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 and Part 75 (commencing with Section 400) of Title 45 of the Code of Federal Regulations, or its successors.
(A) The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs FQHC or RHC sites located in the same or adjacent area with a similar caseload.
(B) In the absence of three comparable FQHCs or RHCs FQHC or RHC sites with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs FQHC or RHC sites located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(D) The department may adopt any further and additional methods of setting reimbursement rates for a newly qualified FQHCs or RHCs FQHC or RHC as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(4) In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have An FQHC or RHC that has experienced changes in their its services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have An FQHC or RHC that has not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs FQHC or RHC sites to the department, but shall be required to identify the comparable FQHCs or RHCs. FQHC or RHC sites.
(k) An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHC's or RHC's clinic base rate as scope-of-service changes. a scope of service change. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service scope of service adjustments as provided in subdivision (e).
(B) An FQHC or RHC may submit requests for scope-of-service scope of service change under this subdivision only within 90 days following the beginning of at any time during the FQHC's or RHC's fiscal year. Any scope-of-service scope of service change request under this subdivision approved by the department shall be retroactive to the first day that Drug Medi-Cal services were rendered and reimbursement for Drug Medi-Cal services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.
(E) Rate changes based on a request for scope-of-service scope of service change under this subdivision shall be evaluated in accordance with Medicare federal reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 and Part 75 (commencing with Section 400) of Title 45 of the Code of Federal Regulations, or its successor.
(F) For purposes of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services FQHC or RHC services and Drug Medi-Cal services.
(B) An FQHC or RHC may submit requests for a scope-of-service scope of service change under this subdivision only within 90 days following the beginning of at any time during the FQHC's or RHC's fiscal year. Any scope-of-service scope of service change request under this subdivision approved by the department shall be retroactive to the first day that specialty mental health services were rendered and reimbursement for specialty mental health services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.
(D) Within 90 days of receipt of the request for a scope-in-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHC's or RHC's projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E) Rate changes based on a request for scope-of-service scope of service change under this subdivision shall be evaluated in accordance with Medicare federal reasonable cost reimbursement principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 and Part 75 (commencing with Section 400) of Title 45 of the Code of Federal Regulations, or its successor.
(F) For the purpose of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services FQHC and RHC services and specialty mental health services.
(n)FQHCs and RHCs
(o) Notwithstanding Section 14104.5 or any other law, an FQHC or RHC may elect to appeal a grievance or complaint concerning ratesetting, scope-of-service changes, a scope of service change, and settlement of cost report audits, in the manner prescribed by Section 14171. 14171 or file a petition for writ of mandate pursuant to Section 1085 of the Code of Civil Procedure in the superior court. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(s) Notwithstanding any other law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific subdivisions (l) and (m) (m) and (n) by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific the provisions of subdivisions (l) and (m), (m) and (n), including all of the following:
14132.101.
(a)Notwithstanding paragraphs (4) and (5) of subdivision (e) of Section 14132.100, a scope-of-service change request, whether mandatory or permissive, shall be timely when filed within 150 days following the beginning of the federally qualified health center's or rural health clinic's fiscal year following the year in which the change occurred.
(b)Notwithstanding subdivision (a), and notwithstanding subdivision (e) of Section 14132.100, a federally qualified health center described in Section 14132.102 shall be deemed to have filed a scope-of-service change in a timely manner upon compliance with the requirements set forth in subdivision (c) of Section 14132.102.