Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-31 - Federally Qualified Health Center Services › Subsection 144-101-II-31.07 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
31.07-1
General Reimbursement
FQHCs are reimbursed in accordance with the requirements
						of section 702 of the
Benefits Improvement and Protection Act (BIPA) of
						2000
, including requirements for a Prospective Payment System.
Reimbursement is generally limited to one core service
						visit, and/or one ambulatory service visit per day. Reimbursement for a second
						core visit is also covered if the member has both an encounter with a
						physician, physician assistant, advanced nurse practitioner or visiting nurse,
						and in addition to that encounter, is seen on the same dayby a licensed
						clinical psychologist, clinical social worker, clinical professional counselor
						or a clinical nurse specialist licensed as an advanced practice clinical nurse
						specialist. An additional visit of any other kind will only be reimbursed for
						unforeseen circumstances as documented in the member's record. The goal remains
						to treat the whole individual during one visit.
Federally Qualified Health Centers may be reimbursed in
						excess of their core and additional (same day) visit rates when providing
						services delineated in the respective sections of the
MaineCare
						Benefits Manual
: Primary Care Case Management Services per Chapter VI,
						Section 1; and Chapter 1.
Any additional center visits that are required in the
						patient's treatment plan that do not qualify as center visits for reimbursement
						purposes are non-billable.
FQHCs have the option of obtaining a separate MaineCare
						provider billing number for the limited purpose of FFS billing and
						reimbursement for such services as x-ray, EKG, inpatient hospital visits and
						other Medicare defined non-FQHC services that are billable under Medicare Part
						B. If a center chooses to bill fee for service for Medicare defined non-FQHC
						services, it may not report costs related to these services on its MaineCare
						cost report.
31.07-2
PPS Reimbursement Methodology
A.
Initial PPS Rates and Annual Adjustments
Effective January 1, 2001, FQHCs will be reimbursed on
						the basis of 100% of the average of their reasonable costs of providing
						MaineCare-covered services during calendar years 1999 and 2000, adjusted to
						take into account any increase or decrease in the approved scope of services
						furnished during the provider's fiscal year 2001 (calculating the amount of
						payment on a per visit basis).
At the start of each subsequent year, beginning in CY
						2002, each FQHC is entitled to the payment amount (on a per visit basis) to
						which the center was entitled under the Act in the previous fiscal year,
						inflated by the percentage increase in the Medicare Economic Index (MEI) for
						primary care services, and adjusted to take into account any increase or
						decrease fora MaineCare approved "change in scope of services."
Newly qualified FQHCs after state fiscal year 2017 will
						have initial payments (calculated on a per visit basis) established either by
						reference to payments to other centers in the same or adjacent areas with a
						similar caseload, or in the absence of such other centers, through cost
						reporting methods. Cost reports must accurately reflect the costs of the
						individual FQHC (i.e. may not be a consolidated report of multiple sites or
						organizations that is not able to distinguish FQHC costs). For each fiscal year
						following the initial year, payment shall be adjusted for MEI and approved
						"change in scope of services." This applies to each new FQHC site or location
						with a separate National Provider Identifier that is opening, regardless of
						affiliation to an existing organization, and regardless of previous service
						delivery.
FQHCs must submit their HRSA Scope of Project for the
						Fiscal Year 1999, or for their first year of operation for FQHCs approved after
						Fiscal Year 1999, plus any subsequent approved Plan of Project
						amendments.
B.
"Change
					 in Scope of Services" Requests and Adjustments
A "change in the scope of services" refers to a change in
						the overall picture of a FQHC's services through a change in the type,
						intensity, duration and/or amount of services.
The following examples are offered as guidance to FQHCs
						to facilitate understanding of the types of changes that may be recognized as a
						"change in scope of services." These examples should not be interpreted as a
						definitive nor comprehensive delineation of the definition of "change of scope
						of services."
(1) The addition of a new
					 covered service or deletion of an existing covered service that is present in
					 the existing PPS rate. Covered services are those which meet the definition of
					 FQHC services as provided in section 1905(a)(2)(C) of the
Social
					 Security Act
;
(2) The
					 addition of a new professional staff (i.e. employed or contracted) who is
					 licensed to perform a covered service that no current professional staff is
					 licensed to perform;
(3) A change
					 in the intensity of a service that fundamentally alters the service delivery
					 model and increases or decreases the quantity of labor and materials consumed
					 by an individual during an average encounter. This change may be attributed to
					 changes in the types of patients served.
An increase or decrease in "scope of services" does
						notnecessarily result from any of the following (although some of these changes
						may occur in conjunction with a "change in scope of services"):
(1) A change in the cost of providing an
					 existing service;
(2) A change of
					 ownership;
(3) A change in status
					 between free-standing and provider-based;
(4) The expansion of an existing service to a
					 new population;
(5) The expansion
					 of the FQHC to a new site which provides the same services;
(6) The addition or reduction of staff
					 members to or from an existing service;
(7) A change in office hours; or,
(8) An increase or decrease in the number of
					 encounters.
It is the FQHC's responsibility to notify the Department
						of any "change in the scope of services" and provide proper documentation to
						support the rate change request. The FQHC must submit either at least six (6)
						months of actual cost data for changes that have already taken place, or twelve
						(12) months of projected costs for anticipated changes.
When an FQHC submits projected costs for an anticipated
						change in the scope of services that amounts to a PPS rate change that is
						greater than or equal to five percent (5%), the Department may request data
						from the FQHC when at least six (6) months of actual data becomes available for
						a rate review and adjustment as determined by the Department. The FQHC must
						also submit a narrative describing the change. Requests for a rate adjustment
						based on a prior change must be received no later than one hundred and fifty
						(150) days after the FQHC's fiscal year end in which the "change in scope of
						services" occurred. The Department will respond with a decision to a rate
						adjustment request within sixty (60) days of receiving a completed application.
						An application is considered complete when the Department confirms that it has
						received all the information needed to process the application.
Adjustments to the PPS rate for the increase or decrease
						in scope of services will be reflected in the PPS rate beginning with services
						provided the first day of the month immediately following either the date the
						Department approves the "change in scope of services" adjustment or the date an
						anticipated change will begin, whichever is later.