Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-28 - Cost-Based Clinic (FQHC, OHF, RHC) Services › Section 5160-28-05 - Federally qualified health center (FQHC) and rural health clinic (RHC) services: prospective payment system (PPS) method for determining payment

Current through all regulations passed and filed through July 1, 2024
(A) A discrete, all-inclusive per-visit
			 payment amount (PVPA) is established for each FQHC PPS service provided at an
			 FQHC or related off-site location and for an RHC PPS service provided at an RHC
			 or related off-site location.
(1) For all
			 FQHC or RHC sites that are already enrolled as medicaid providers,
			 the Ohio department of medicaid ( ODM) establishes new PVPAs equal to the current PVPAs
			 revised to reflect the latest available medicare economic index (MEI)
			 percentage. The new PVPAs are established by October first of each year and are
			 in effect from October first through the following September
			 thirtieth.
(2)
									On the effective date of this rule, the following
			 amounts ("FQHC PVPA add-on amounts") are added to the PVPA for the respective
			 FQHC PPS service:
(a)
										Medical, fifteen dollars and eighty
			 cents;
(b)
										Dental, sixteen dollars and fifty
			 cents;
(c)
										Behavioral health, eighteen dollars and twenty
			 cents;
(d)
										Physical therapy or occupational therapy, nine dollars
			 and seventy cents;
(e)
										Speech pathology and audiology, fifteen dollars and
			 twenty cents;
(f)
										Podiatry, six dollars and sixty cents;
(g)
										Vision, ten
			 dollars and fifty cents;
(h)
										Chiropractic, nine dollars and twenty cents;
			 and
(i)
										Transportation, two dollars and fifty
			 cents.
(3)
									Beginning July 1, 2025, the FQHC PVPA add-on amounts
			 described in paragraph (A)(2) of this rule are reduced to the following
			 amounts:
(a)
										Medical, ten dollars and fifty cents;
(b)
										Dental, eleven
			 dollars;
(c)
										Behavioral health, twelve dollars and twenty
			 cents;
(d)
										Physical therapy or occupational therapy, six dollars
			 and forty cents;
(e)
										Speech pathology and audiology, ten dollars and twenty
			 cents;
(f)
										Podiatry, four dollars and forty cents;
(g)
										Vision, seven
			 dollars;
(h)
										Chiropractic, six dollars and twenty cents;
			 and
(i)
										Transportation, one dollar and seventy
			 cents.
(4) When an enrolled
			 FQHC or RHC site requests adjustment of a PVPA, ODM may establish a new PVPA
			 based on a cost report in accordance with rule
			 5160-28-04 of the Administrative
			 Code.
(5) For an FQHC or RHC
			 site that is enrolling as a new medicaid provider or an FQHC site that is
			 adding a new FQHC PPS service, ODM establishes an initial PVPA in accordance
			 with the following procedure:
(a) First, the
			 initial PVPA is set equal to the corresponding PVPA of other FQHC or RHC sites
			 in the immediate area that are similar in size, caseload, and scope of
			 services. If no such FQHC or RHC site exists, then the initial PVPA is set
			 equal to the current PVPA at the applicable statewide sixtieth percentile for
			 the appropriate FQHC or RHC classification .
(b) This initial
			 PVPA remains in effect until a new PVPA is established.
(c) After the initial PVPA is set, the FQHC
			 or RHC site submits a cost report in accordance with rule
			 5160-28-04 of the Administrative
			 Code. A new PVPA is established 
										based on the cost report and is
			 revised to reflect any changes in the MEI that have occurred since the cost
			 report was submitted.
(d)
			 Thereafter, the PVPA is revised in accordance with paragraph (A)(1) of this
			 rule.
(6) For an FQHC PPS
			 service only, if no current PVPA at the applicable statewide sixtieth
			 percentile is available, then the initial PVPA, P, is obtained by the formula P
			 = M × (S / E), rounded up to the next whole dollar.
(a)
										" M" is the greater of two figures:
(i) The current PVPA for medical services at
			 the applicable statewide sixtieth percentile for FQHC sites; or
(ii) The current PVPA for medical services at
			 the particular FQHC site.
(b)
										" S" is the medicaid maximum payment amount (or the
			 median of the medicaid maximum payment amounts) for a procedure (or a group of
			 procedures) typical of the service for which a PVPA is being
			 established.
(c)
										" E" is the
			 medicaid maximum non-facility payment amount for a mid-level evaluation and
			 management service (office visit) for an established patient.