Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 26 - Federally-Qualified Health Center Services › Section 13 CSR 70-26.010 - MO HealthNet Program Benefits for Federally-Qualified Health Center Services

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule is being amended to reflect the
				  current cost report form and related worksheet, provide an exemption to the
				  cost report filing requirements, and to clarify documentation and record
				  retention requirements, interim payments, and final
				  settlements.
(1) Pursuant to
				the Omnibus Reconciliation Act of 1989, this regulation provides the payment
				methodology used to reimburse federally-qualified health centers (FQHCs) the
				allowable costs which are reasonable for the provision of FQHC-covered services
				to MO HealthNet participants.
(2)
				General Principles.
(A) The MO HealthNet
				program shall reimburse FQHC providers based on the reasonable cost of
				FQHC-covered services related to the care of MO HealthNet participants (within
				program limitations) less any copayment or deductible amounts which may be due
				from MO HealthNet participants effective for services on and after July 1,
				1990.
(B) Reasonable costs shall be
				determined by the MO HealthNet Division based on desk reviews of the applicable
				cost reports and may be subject to adjustment based on field audits. Reasonable
				costs shall not exceed the Medicare cost principles set forth in 42 CFR Part
				413.
(C) Reasonable costs shall be
				apportioned to the MO HealthNet program based on a ratio of covered charges for
				MO HealthNet participants to total charges. Charges mean the regular rate for
				various services which are established uniformly for both MO HealthNet
				participants and other patients. MO HealthNet charges shall include MO
				HealthNet managed care charges for covered services.
(D) An FQHC shall submit a MO HealthNet cost
				report in the manner prescribed by the state MO HealthNet agency. The cost
				report shall be submitted within five (5) months after the close of the FQHC's
				reporting period. An extension may be granted upon the request of the FQHC and
				the approval of the MO HealthNet Division with an agreed upon date of
				completion. The request must be in writing and postmarked prior to the first
				day of the sixth month following the FQHC's fiscal year end.
1. An FQHC may be exempt from filing a
				Missouri Medicaid Title XIX Cost Report if MO HealthNet reimbursement is
				twenty-five thousand dollars ($25,000) or less for the facility's reporting
				period. The facility must submit a request to the division to waive the cost
				report filing requirement within five (5) calendar months after the close of
				the facility's reporting period. To request an exemption for the cost report
				filing requirement, the following information must be submitted to the division
				for review and approval:
A. A Low or No
				Missouri Medicaid Utilization Waiver Request Form. This form may be obtained
				from the division. The form must be fully completed and signed by an officer or
				administrator; and
B. Worksheet S
				series of the Medicare Cost Report. The Worksheet S must be completed and
				signed by an officer or administrator.
(E) An FQHC cost report shall be submitted
				and certified by an officer or administrator of the provider. Failure to file a
				cost report within the prescribed period, except as expressly extended in
				writing by the state agency, may result in the imposition of sanctions as
				described in
				13
				CSR 70-3.030.
(F) Authenticated copies of agreements and
				other significant documents related to the provider's operation and provision
				of care to MO HealthNet participants must be included with the cost report at
				the time of filing unless current and accurate copies have already been filed
				with the division. Material which must be submitted includes, but is not
				limited to, the following as applicable:
1.
				Audited financial statements prepared by an independent accountant and
				submitted to the MO HealthNet Division when available, including explanatory
				notes, disclosure statements, and management letter;
2. Contracts or agreements involving the
				purchase of facilities or equipment during the cost reporting period if
				requested by the division, the department, or its agents;
3. Contracts or agreements with related
				parties;
4. Schedule A detailing
				all grants, gifts, donations, and income from endowments, including amounts,
				restrictions, and use;
5.
				Explanations of grants, gifts, donations, or endowments for which related
				expenses have not been offset on Worksheet 1-B of the MO HealthNet Division
				FQHC cost report. If subsequently requested by the division or its contracted
				agents, documentation of related expenditures will also be submitted;
6. Leases or rental agreements, or both,
				related to the activities of the provider;
7. Management contracts; and
8. Working trial balance actually used to
				prepare the cost report with line number tracing notations or similar
				identifications.
(G)
				Records.
1. Maintenance and availability of
				records.
A. A provider must keep records in
				accordance with generally accepted accounting principles (GAAP) and maintain
				sufficient internal control and documentation to satisfy audit requirements and
				other requirements of this rule, including reasonable requests by the division
				or its authorized agent for additional information.
B. Adequate documentation for all line items
				on the cost report shall be maintained by a provider. Upon request, all
				original documentation and records must be made available for review by the
				division or its authorized agent at the same site at which the services were
				provided. Copies of documentation and records shall be submitted to the
				division or its authorized agent upon request.
C. Records of related organization, as
				defined by
				42 CFR
				413.17, must be available upon
				demand.
D. The division shall
				retain all uniform cost reports submitted by the FQHCs for seven (7) years
				after the final settlement relating to a cost report is finalized, including
				the resolution of any subsequent appeals or other administrative actions
				pertaining to the cost report.
E.
				Each facility shall retain all financial information, data, and records
				relating to the operation and reimbursement of the facility for seven (7) years
				after the final settlement relating to a cost report is finalized, including
				the resolution of any subsequent appeals or other administrative actions
				pertaining to the cost report, and shall maintain those reports pursuant to the
				record-keeping requirements of
				42 CFR
				413.20.
2. Adequacy of records.
A. The division may suspend reimbursement or
				reduce payments to the appropriate fee schedule amounts if it determines that
				the FQHC does not maintain records that provide an adequate basis to determine
				payments under MO HealthNet.
B. A
				suspension or reduction will continue until the FQHC demonstrates, to the
				division's satisfaction, that it has an ongoing and current process in place to
				ensure the maintenance of adequate records.
(H) Audits.
1. Any cost report submitted may be subject
				to field audit by the division or its authorized agent.
2. A provider shall have available at the
				field audit location one (1) or more knowledgeable persons authorized by the
				provider and capable of explaining the provider's accounting and control system
				and cost report preparation, including all attachments and
				allocations.
3. If a provider
				maintains any records or documentation at a location which is not the same as
				the site where services were provided, the provider shall transfer the records
				to the same facility at which the services were provided, or the provider must
				reimburse the division or its authorized agent for reasonable travel costs
				necessary to perform any part of the field audit in any off-site location, if
				the location is acceptable to the division.
(I) Change in Provider Status. The next
				payment due the provider after the division has received the notification of
				the termination of participation in the MO HealthNet program or change of
				ownership may be held by the division until the cost report is filed. Upon
				receipt of a cost report prepared in accordance with this rule, the payments
				that were withheld will be released.