a)
Definitions
"Behavioral Health Services", for the purposes of this
Section, means services provided by a licensed clinical psychologist, licensed
clinical social worker or licensed clinical professional counselor.
"Center", for the purposes of this Section, means both a
federally qualified health center and a rural health clinic.
"Federally Qualified Health Center" or "FQHC" means a health
care provider that receives a grant under Section 330 of the Public Health
Service Act ( Public Law 78-410 ) (
42 USC
1395 x(aa)(3) ) or has been determined to
meet the requirements for receiving such a grant by the Health Resources and
Services Administration, U.S. Department of Health and Human Services.
"Rural Health Clinic" or "RHC" means a health care provider
that has been designated by the Public Health Service, U.S. Department of
Health and Human Services, or by the Governor, and approved by the Public
Health Service, in accordance with the Rural Health Clinics Act ( Public Law
95-210 ) (
42 USC
1395 x(aa)(2) ) to be an RHC.
b) Reimbursement
The Center will be reimbursed under a prospective payment
system for 100 percent of the average of the costs that are reasonable and
related to the cost of furnishing such services by the Center in accordance
with the provisions of federal law (
42 USC
1396 a(aa) ). Baseline payment rates will be
determined individually for each enrolled Center. Once determined, the baseline
payment rate will be adjusted annually using the Medicare Economic Index (MEI).
Payment for services provided on or after January 1, 2001, shall be made using
specific rates for each Center as specified in this Section.
1) Baseline Payment Rates
A) For each Center, the Department will
calculate a baseline medical encounter rate and, for each Center that is
enrolled with the Department to provide Behavioral Health Services or dental
services, the Department will calculate a baseline Behavioral Health Services
or dental encounter rate, using the methodology specified in this subsection
(b).
i) The cost basis for the baseline rates
shall be drawn from individual Center cost reports for Center fiscal years
ending in 1999 and 2000 or, in the instance of a Center that did not operate
during the entirety of those periods, cost reports that cover the portions of
those periods during which the Center was in operation.
ii) Pending federal approval, for dates of
service provided by an FQHC on or after January 1, 2006, the cost basis for the
baseline rates shall be the greater of an encounter rate using the criteria
under subsection (b)(1)(A)(i) of this Section, or the same criteria that uses
the Center's cost reports ending in 2002 and 2003 in place of cost reports
ending in 1999 and 2000.
B) The baseline payment rates shall be based
upon allowable costs, reported by the Center, that are determined by the
Department to be reasonable and efficient. The method for determining allowable
cost factors is similar to that used for Medicare (
42 USC
1395 g ), with the following significant
differences. The Department's methodology shall:
i) Consider costs associated with services
not covered under Medicare (e.g., pharmacy, patient transportation, medical
case management, health education, nutritional counseling).
ii) Apply reasonable constraints on allowable
cost, as described in subsection (b)(10) of this Section.
iii) Apply reasonable constraints on the
total cost per encounter.
C) The baseline payment rates for a Center
shall be the average (arithmetic mean) of the annual reasonable costs per
encounter, calculated separately for each of the fiscal years for which cost
report data must be submitted using the methodology specified in subsections
(b)(2), (3) and (4) of this Section for the medical encounter rate, dental
encounter rate, and Behavioral Health Services encounter rate,
respectively.
2) Annual
Reasonable Cost Per Medical Encounter
A) The
annual reasonable cost per medical encounter shall be the lesser of:
i) The annual cost per encounter, as
calculated in subsection (b)(2)(D) of this Section; or
ii) The reasonable cost of providing a
medical encounter, which shall be 105 percent of the Statewide median of the
calculated annual costs per encounter for FQHCs or RHCs, as the case may
be.
B) The core services
component.
The core services component is the sum of the following two
components:
i) The allowable direct
cost per encounter, which is the quotient of the allowable direct cost, as
defined in subsection (b)(1)(B) of this Section, for core services divided by
the greater of the number of encounters reported by direct staff (e.g., staff
specified in subsection (b)(10)(A) and, for the determination of encounter
payment rates effective prior to January 1, 2002, subsection (b)(10)(C)); or
the number of encounters resulting from the application of the minimum
efficiency standards found in subsections (b)(10)(A) and (b)(10)(C);
and
ii) The allowable overhead cost
per encounter, which is the product of the allowable direct cost per encounter
multiplied by the Center's allowable overhead rate factor.
C) Supplemental services component.
The supplemental services component is the sum of the
following two components:
i) The
allowable supplemental cost per encounter, which is the quotient of the cost of
services (e.g., pharmacy, patient transportation, medical case management,
health education, nutritional counseling), excepting core services, dental
services and, effective January 1, 2002, Behavioral Health Services, provided
by the Center, divided by the greater of the number of encounters reported by
direct staff; or the number of encounters resulting from application of the
minimum productivity standards found in subsections (b)(10)(A) and (b)(10)(C)
of this Section; and
ii) The
allowable overhead cost per encounter, which is the product of the allowable
supplemental cost per encounter multiplied by the Center's allowable overhead
rate factor.
D) Annual
cost per encounter.
The annual cost per medical encounter is the sum of the core
services component, as determined in subsection (b)(2)(B) of this Section, and
the supplemental services component, as determined in subsection
(b)(2)(C).
3)
Annual Reasonable Cost Per Dental Encounter
A)
The annual reasonable cost per dental encounter shall be the lesser of:
i) The annual cost per encounter, as
calculated in subsection (b)(3)(B) of this Section; or
ii) The reasonable cost of providing a dental
encounter, which shall be 105 percent of the Statewide median of the calculated
annual costs per encounter for FQHCs or RHCs, as the case may be.
B) Annual cost per encounter.
The annual cost per encounter is the sum of the following two
components:
i) The allowable direct
cost per encounter, which is the quotient of the allowable direct dental cost,
as defined in subsection (b)(1)(B), divided by the greater of the number of
encounters reported by direct dental staff; or the number of encounters
resulting from the application of the minimum efficiency standard found in
subsection (b)(10)(B); and
ii) The
allowable overhead cost per encounter, which is the product of the allowable
direct cost per encounter multiplied by the Center's allowable overhead rate
factor.
4)
Annual Reasonable Cost Per Behavioral Health Service Encounter
Effective for services provided on or after January 1, 2002,
a separate annual reasonable cost per Behavioral Health Service encounter shall
be determined.
A) The annual
reasonable cost per Behavioral Health Service encounter shall be the lesser of
the following:
i) The annual cost per
encounter, as calculated in subsection (b)(4)(B) of this Section.
ii) The reasonable cost of providing a
Behavioral Health Service encounter, which shall be 105 percent of the
Statewide median of the calculated annual cost per encounter for FQHCs or RHCs,
as the case may be.
B)
Annual cost per encounter.
The annual cost per encounter is the sum of the following two
components:
i) The allowable direct
cost per encounter, which is the quotient of the allowable direct cost for
Behavioral Health Services, as defined in subsection (b)(1)(B) of this Section,
divided by the greater of the number of encounters reported by direct
behavioral health staff; or the number of encounters resulting from the
application of the minimum efficiency standard found in subsection (b)(10)(C);
and
ii) The allowable overhead cost
per encounter, which is the product of the allowable direct cost per encounter
multiplied by the Center's allowable overhead rate factor.
5) For any individual eligible
under the medical assistance programs, a Center may bill only one medical
encounter, one dental encounter, and one behavioral health encounter per day. A
Center will be reimbursed for a service only if it has enrolled with the
Department to provide that service.
6) Claims submitted to the Department must
identify all services provided during the encounter.
7) Cost Basis
Each Center must annually complete a cost report, in a format
specified by the Department, for the Center's fiscal year. Each FQHC must also
annually submit a copy of financial statements audited by an independent
Certified Public Accountant. The cost report and audited financial statements
must be filed with the Department within 180 days after the close of the
Center's fiscal year, except for cost reports and audited financial statements
for Center fiscal years 1999 and 2000 which, in the case of FQHCs, must be
filed with the Department no later than November 30, 2001, and in the case of
RHCs, must be filed no later than March 30, 2002. Except for the first year
during which the Center begins operations, the cost report must cover a full
fiscal year ending on June 30 or other fiscal year that has been approved by
the Department. Payments will be withheld from any Center that has not
submitted the cost report by the applicable filing date, and no payments will
be made until such time as the reports or audited statements are received and
approved by the Department.
8) Establishment of Initial Year Payment
Amount for a New Center
For any Center that begins operation on or after January 1,
2001, the payment rate per encounter shall be the median of the payment rates
per encounter of neighboring FQHCs or RHCs with similar caseloads, as
determined by the Department. If the Department determines that there are no
such comparable Centers, then the rate per encounter shall be the median of the
payment rates per encounter Statewide for all FQHCs or RHCs, as the case may
be.
9) Rate Adjustments
A) Initial rate determinations.
i) On or about January 1, 2002, the
Department shall determine the medical and dental encounter rates for each
participating FQHC. These rates shall be paid for services provided on or after
January 1, 2001. Claims submitted and adjudicated prior to the entry of these
rates into the Department's claims processing system shall be reconciled for
each affected FQHC.
ii) On or about
January 1, 2003, the Department shall determine the medical and dental
encounter rates for each participating RHC. These rates shall be paid for
services provided on or after January 1, 2001. Claims submitted and adjudicated
prior to the entry of these rates into the Department's claims processing
system shall be reconciled for each affected RHC.
B) Annual adjustment.
i) Beginning January 1, 2002, and annually
thereafter, except as specified in subsection (b)(9)(B)(ii) of this Section,
the Department will adjust baseline rates by the most recently available MEI.
The adjusted rates shall be paid for services provided on or after the date of
adjustment.
ii) In the instance of
a Center that provided Behavioral Health Services prior to January 1, 2002, for
the purpose of applying the January 1, 2002, adjustment by the most recently
available MEI, the baseline medical services encounter rate applicable for
services provided from January 1, 2001, through December 31, 2001, shall be
redetermined after removal of costs and encounters attributable to Behavioral
Health Services.
C)
Scope of service adjustment.
If a Center significantly changes its scope of services, the
Center may request that new baseline encounter rates be determined. Adjustments
to encounter rates will be made only if the change in the scope of services
results in the inclusion of Behavioral Health Services or dental services or a
difference of at least five percent from the Center's current rate. The
Department may initiate a rate adjustment, based on audited financial
statements or cost reports, if the scope of services has been modified to
include Behavioral Health Services or dental services or would otherwise result
in a change of at least five percent from the Center's current rate.
10) Reasonable Cost
Considerations
The following minimum efficiency standards will be applied to
determine reasonable cost:
A) Medical
direct care productivity.
The Center must average 4,200 encounters annually per
full-time equivalent (FTE) for physicians and 2,100 encounters per FTE for
mid-level health care staff (i.e., physician assistants, nurse practitioners,
specialized nurse practitioners and nurse midwives).
B) Dental direct care productivity.
The Center must average
1.5 encounters per hour
per FTE for dentists.
C)
Behavioral health direct care productivity.
The Center must average 2,100 annual encounters per FTE for
licensed clinical psychologists, licensed clinical social workers and licensed
clinical professional counselors.
D) Guideline for non-physician health care
staff.
The maximum ratio of staff is four FTE non-physician health
care staff for each FTE staff subject to the direct care productivity standards
in subsections (b)(10)(A) and (B) of this Section.
E) Allowable overhead.
The maximum Medicaid allowable overhead cost is 35 percent of
allowable total cost.
11) Adjustments for Medical Services Paid for
by a Managed Care Organization (MCO)
The Department shall make payment adjustments to a Center if
it provides care through a contractual arrangement with a Medicaid MCO and is
reimbursed an amount, reported to the Department, that is less than the minimum
payment required in
42 USC
1396 a(aa). The amount of any such payment
adjustment shall be at a fixed annual rate as determined by the Department. For
each Center so eligible, a payment adjustment shall take into consideration the
total payments made by the MCO to the Center (including all payments made on a
service-by-service, encounter or capitation basis). In the event that Center
cost data related to MCO services are unavailable to the Department, an
estimate of such costs may be used that takes into consideration other relevant
data. Adjustments will be made, at least quarterly, only for Medicaid eligible
services. All such services must be defined in a contract between the Center
and the MCO. Such contracts must be made available to the Department.
12) Audits
All cost reports will be audited by the Department. The
Center will be advised of any adjustment resulting from these audits.
13) Alternate Payment Methodology
for Government-Operated Centers
A) A Center
operated by a State or local government agency may elect to be reimbursed under
the alternate payment methodology described in this subsection
(b)(13).
B) The State or local
government agency shall enter into an interagency or intergovernmental
agreement, as appropriate, with the Department that specifies the
responsibilities of the two parties with respect to services provided by the
Center and the funding of those services.
C) The Center operated by a State or local
government agency shall be reimbursed by the Department on a per encounter
basis according to the provisions of subsections (b)(1) through (11) of this
Section.
D) The State or local
government agency shall certify the expenditure of public funds in excess of
reimbursement received from the Department, under subsection (b)(13)(C) of this
Section, and any reimbursement from other payers (e.g., an insurance company, a
managed care organization) for services provided to individuals eligible for
medical assistance programs administered by the Department, provided the funds
were not derived from a federal funding source or were not otherwise used as a
State or local match for federal funds. The certification shall be in the form
and format specified by the Department. The certification shall be filed within
30 days after the submission of the annual cost report. The certification shall
compare expenditures within that cost reporting period to payments received or
receivable for that same period.
E)
The certified expenditures shall be used by the Department to claim federal
financial participation. Federal funds resulting from the claiming of the
certified expenditures shall be distributed, according to the provisions of the
agreement referenced in subsection (b)(13)(B) of this Section, to the State or
the government agency that operates the Center that provided the
services.
14) Alternate
Payment Methodology for Certain Qualifying Centers
A) No later than 30 days after the initial
rate determination specified in subsection (b)(9)(A) of this Section, the
Department shall determine the eligibility of each Center for this alternative
payment methodology. A Center will qualify for this alternative payment
methodology if the Department's estimate of the total amount to be paid to the
Center for services provided during the 12-month period ending December 31,
2001, under the reimbursement policy and rates in effect prior to the initial
rate determination, is greater than the total amount that will be paid for
those same services under the initial rates. The Department shall notify each
qualifying Center, in writing, of the result of this determination.
B) A qualifying Center may, for services
provided from January 1, 2002 through December 31, 2002, elect to be reimbursed
under the alternate payment methodology described in this subsection (b)(14). A
qualifying Center must notify the Department, in writing, no later than 30 days
after the date of the written notification from the Department, of its election
to be reimbursed under this alternative payment methodology.
C) A Center electing this alternative payment
system shall be reimbursed by the Department on a per encounter basis according
to the provisions of subsections (b)(1) through (11) of this Section, except
the medical encounter payment rate shall be increased by an amount equal to
twice the quotient resulting from the Department's estimate of the difference
between the total amount to be paid to the Center for services provided during
the 12-month period ending December 31, 2001, under the initial rates as
determined in subsection (b)(9)(A); and the total amount that would have been
paid under the payment rates in effect prior to the initial rate determination,
divided by the Department's estimate of total medical encounters during the
12-month period ending December 31, 2001.
15) Alternate Behavioral Health Payment
Methodology for Certain Qualifying Centers
Centers that are certified by the Department of Human
Services-Division of Mental Health, or the Department of Children and Family
Services to provide Behavioral Health Services may elect an alternate payment
methodology for their Behavioral Health Services. An election of this alternate
payment methodology will allow the Centers to be reimbursed under the
provisions of 59 Ill. Adm. Code 132 for Behavioral Health Services provided. A
qualifying Center must notify the Department in writing, no later than 30 days
after the date of the written notification from the Department, of its election
to be reimbursed under this alternate payment methodology.
16) All service sites operated by a Center
shall be reimbursed using the Center's established encounter rates, except in
the instance where the site submitted separate cost reports and separate
baseline rates were determined for the site.
c) Rate Appeals Process
1) All appeals of audit adjustments or rate
determinations must be submitted in writing to the Department. Appeals must be
submitted within 60 calendar days after the notification of such adjustments or
rate determinations. If upheld, the revised audit adjustment or rate
determination shall be made effective as of the beginning of the rate
period.
2) To be accepted for
review, the written appeal shall include the following:
A) The current approved reimbursement rate,
allowable costs, and the additional reimbursable costs sought through the
appeal.
B) A clear, concise
statement of the basis for the appeal.
C) A detailed statement of financial,
statistical, and related information in support of the appeal, indicating the
relationship between the additional reimbursable costs as submitted and the
circumstances creating the need for increased reimbursement.
D) A statement by the Center's chief
executive officer or financial officer that the application of the rate appeal
and information contained in the Center's reports, schedules, budgets, books,
and records submitted are true and accurate.
3) Rate appeals may be considered for the
following reasons:
A) Mechanical or clerical
errors committed by the provider in reporting historical expenses used in the
calculation of allowable costs.
B)
Mechanical or clerical errors committed by the Department in auditing
historical expenses as reported and/or in calculating reimbursement
rates.
4) The Department
shall rule on all appeals within 120 calendar days after receipt of the
complete appeal, except that, if additional information is required from the
facility, the period shall be extended until such time as the information is
provided.
5) Appeals shall be
submitted to the Department's Office of Health Finance, 201 South Grand Avenue
East, Springfield, Illinois 62763-0002.
