Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-56 - FEDERALLY QUALIFIED HEALTH CENTER REIMBURSEMENT › Section 560-X-56-.04 - Reimbursement Methodology

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 Medicaid prospective payment system (PPS) for Federally Qualified Health
			 Centers (FQHCs) was enacted into law under section 702 of the Medicare,
			 Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000. As
			 described in section 1902(aa) of the Social Security Act, FQHCs will be paid
			 under a prospective payment system effective January 1, 2001. Prior to
			 enactment of BIPA, FQHCs were reimbursed by an established encounter rate based
			 on 100% of reasonable allowable cost for Medicaid covered services provided by
			 the FQHC. With the implementation of BIPA, FQHC providers that provided
			 Medicaid covered services for the period October 1, 2000, through December 31,
			 2000, will file a cost report and it will be settled. For the period January 1,
			 2001, through September 30, 2001, Alabama Medicaid Agency will pay FQHCs 100%
			 of the average of their reasonable costs of providing Medicaid covered services
			 during FY 1999 and FY 2000, adjusted to take into account any increase (or
			 decrease), see paragraph (3) below, in the scope of services furnished during
			 FY 2001 by the FQHC (calculating the payment amount on a per visit basis).
			 Beginning in FY 2002, and for each fiscal year thereafter, each FQHC is
			 entitled to the payment amount (on a per visit basis) to which the FQHC was
			 entitled to in the pervious fiscal year, increased by the percentage increase
			 in the Medicare Economic Index (MEI) for primary car services, and adjusted to
			 take into account any increase (or decrease) in the scope of services furnished
			 by the FQHC during that fiscal year.
(2) Reimbursement for an enrolled out-of
			 state FQHC will be the lesser of the encounter rate established by the Medicaid
			 Department of the out-of-state FQHC or the average encounter rate established
			 by Alabama Medicaid for in-state facilities.
(3) A new FQHC provider or a provider who
			 constructs, leases, or purchases a facility, or has a Medicaid approved change
			 in the scope of service, can request reimbursement based on an operating
			 budget, subject to the ceiling established under this rule. After the actual
			 cost report is received and desk reviewed for the budget period, an actual
			 encounter rate will be determined. In this event, the FQHC may be subject to a
			 retroactive adjustment based on the difference between budgeted and actual
			 allowable costs. This difference may be subject to settlement within thirty
			 (30) days after written notification by Medicaid to the provider of the amount
			 of the difference. After the initial year, payment shall be set using the MCI
			 methods used for other FQHCs. An FQHC that has a change of ownership can retain
			 the previous owner's encounter rate if desired.
(4) Costs Reimbursed by Other Than FQHC
			 Encounter Rate. Costs that are reimbursed by other Alabama Medicaid Agency
			 programs will not also be reimbursed in the FQHC Program. Examples of such
			 reimbursements include, but are not limited to:
(a) Maternity Waiver - Primary Contractor
(Note: Costs for Maternity Waiver sub-contractors are not an
				allowable cost and will be shown only in the non-reimbursable section of the
				cost report.)
(b)
			 Prescription Drugs by enrolled pharmacy providers
(c) In-patient and out-patient surgical
			 service fee-for-service payments.
In order to keep from paying for such services twice, the
				payments for the programs above will be deducted from the FQHC
				settlements.