23 Miss. Code. R. 212-1.5 - Reimbursement
The Division of Medicaid reimburses Rural Health Clinic (RHC) providers at a prospective payment system (PPS) rate per encounter and/or alternative payment methodology (APM).
A. The Division of Medicaid uses the PPS
methodology for reimbursement to RHC providers per encounter as described
below:
1. For services provided on and after
January 1, 2001, during calendar year 2001, payment for services shall be
calculated, on a per visit basis, in an amount equal to one hundred percent
(100%) of the average of the RHC's reasonable costs of providing the Division
of Medicaid covered services during fiscal years 1999 and 2000. If a RHC first
enrolls during fiscal year 2000, the rate will only be computed from the fiscal
year 2000 Medicaid cost report. The PPS baseline calculation shall include the
cost of all Medicaid covered services including other ambulatory services that
were previously paid under a fee-for-service basis. This rate will be adjusted
to take into account any increase or decrease in the scope of services
furnished by the RHC during fiscal year 2001.
2. Payment rates may be adjusted by the
Division of Medicaid pursuant to changes in federal and/or state laws or
regulations.
3. Beginning in
calendar year 2002, and for each calendar year thereafter, the RHC is entitled
to the payment amount, on a per visit basis, to which the RHC was entitled to
in the previous year, increased by the percentage increase in the Medicare
Economic Index (MEI) for primary care services for that calendar year, and
adjusted to take into account any increase or decrease in the scope of services
furnished by the RHC during that calendar year. The rate will be retroactively
adjusted to reflect the MEI.
4. New
clinics that qualify for the RHC program after January 1, 2001, will be
reimbursed the initial PPS rate which will be based on the rates established
for other RHCs located in the same or adjacent area with a similar caseload. In
the absence of comparable RHCs, the rate for the new provider will be based on
projected costs. The RHC's Medicare final or Amended final settlement cost
report for the initial cost report period year will be used to calculate a PPS
base rate that is equal to one hundred percent (100%) of the RHC's reasonable
costs of providing Medicaid covered services. If the initial cost report period
represents a full year of RHC services, this final settlement rate will be
considered the base rate. If the initial RHC cost report period does not
represent a full year, then the rate from the first full year cost report will
be used as the clinic's base rate. For each subsequent calendar year, the
payment rate will be equal to the rate established in the preceding calendar
year, increased by the percentage increase in the MEI for primary care services
that is published in the Federal Register in the fourth (4) quarter of the
preceding calendar year.
B. The Division of Medicaid reimburses no
more than four (4) encounters per beneficiary per day, provided that each
encounter represents a different provider type, as the Division of Medicaid
only reimburses for one (1) medically necessary encounter per beneficiary per
day for each of the provider types listed in Miss. Admin. Code, Title 23, Part
212, Rule
1.2.A. except if the beneficiary
experiences an illness or injury requiring additional diagnosis or treatment
subsequent to the first encounter. Services provided by a nurse practitioner
(NP) or physician assistant (PA) are reimbursed the full PPS rate.
C. The Division of Medicaid reimburses for
telehealth services which meet the requirements in Miss. Admin. Code Part 225
as follows:
1. An encounter for face-to-face
telehealth services provided by the RHC acting as a distant site
provider.
2. A fee per completed
transmission for telehealth services provided by the RHC acting as an
originating site provider. The RHC may not bill for an encounter visit unless a
separately identifiable service is performed. The originating site facility fee
will be paid at the existing fee-for-service rate in effect as of January 1,
2021.
3. Reimburses a RHC for both
the distant and originating provider site when such services are appropriately
provided by the RHC.
D.
An alternative payment methodology is an additional fee for certain services
provided by the RHC.
1. The Division of
Medicaid reimburses a RHC a fee in addition to the PPS rate when certain
services are provided outside the Division of Medicaid's regularly scheduled
office hours.
a) The Division of Medicaid
defines regularly scheduled office hours as the hours between 8:00 a.m. and
5:00 p.m., Monday through Friday, excluding Saturday, Sunday and federal and
state holidays, referred to in Miss. Admin. Code, Part 212, Rule
1.4.B.1. as "office hours".
b) The Division of Medicaid permits RHCs to
set regularly scheduled office hours outside of the Division of Medicaid's
definition of office hours, referred to in Miss. Admin. Code, Part 212, Rule
1.4.C.1. as "RHC established office
hours".
c) The RHC must maintain
records indicating RHC established office hours and any changes including:
1 The date of the change,
2 The RHC established office hours prior to
the change, and
3 The new RHC
established office hours.
d) The Division of Medicaid reimburses a fee
in addition to the PPS rate when the encounter occurs:
1 During the RHC's established office hours
which are set outside of the Division of Medicaid's office hours, or
2 Outside of the Division of Medicaid's
office hours or the RHC's established office hours only for a condition which
is not life-threatening but warrants immediate attention and cannot wait to be
treated until the next scheduled appointment during office hours or the RHC
established office hours.
e) The Division of Medicaid reimburses only
the appropriate PPS rate for an encounter scheduled during office hours or
RHC's established office hours but not occurring until after office hours or
RHC established office hours.
E. The Division of Medicaid reimburses an RHC
the PPS rate for the administration, insertion, and/or removal of certain
categories of physician administered drugs (PADs), referred to as Clinician
Administered Drug and Implantable Drug System Devices (CADDs), reimbursed under
the pharmacy benefit to the extent the CADDs were not included in the
calculation of the RHC's PPS rate.
1. CADDs
are located on the Division of Medicaid's website.
2. CADDs not included on the Division of
Medicaid's list of CADD-classified drugs will be denied if billed through the
pharmacy point-of-sale (POS).
F. If a physician employed by an RHC provides
physician services at an inpatient, outpatient, or emergency room hospital
setting, the services must be billed under the individual physician's Medicaid
provider number and payment will be made directly to the physician. The
financial arrangement between the physician and the RHC must be handled through
an agreement.
G. Change in the
Scope of Services
1. An RHC must notify the
Division of Medicaid in writing of any change in the scope of services by the
end of the calendar year in which the change occurred, including decreases in
scope of services. The Division of Medicaid will adjust an RHC PPS rate if the
following criteria are met:
a) The RHC can
demonstrate there is a valid and documented change in the scope of services,
and
b) The change in scope of
services results in at least a five percent (5%) increase or decrease in the
RHC PPS rate for the calendar year in which the change in scope of service took
place.
2. An RHC must
submit a request for an adjustment to its PPS rate no later than one hundred
eighty (180) days after the settlement date of the RHC Medicare final
settlement cost report for the RHC's first full fiscal year of operation with
the change in scope of services. The request must include the first final
settlement cost report that includes twelve (12) months of costs for the new
service. The adjustment will be granted only if the cost related to the change
in scope of services results in at least a five percent (5%) increase or
decrease in the RHC PPS rate for the calendar year in which the change in scope
of services took place. The cost related to a change in scope of services will
be subject to reasonable cost criteria identified in accordance with federal
regulations.
3. It is the
responsibility of the RHC to notify the Division of Medicaid of any change in
the scope of service(s) and provide the required proper and valid documentation
to support the rate change. Such required documentation must include, at
minimum, a detailed working trial balance demonstrating the increase or
decrease in the RHC's PPS rate as a result of the change in scope of
service(s). The Division of Medicaid will require the RHC to provide such
documentation in a format acceptable to the Division of Medicaid, including
providing such documentation upon the Division of Medicaid's pre-approved
forms. The Division of Medicaid will also request additional information as it
sees fit in order to sufficiently determine whether any change in scope of
service(s) has occurred. The instructions and forms for submitting a request
due to a change in scope of services can be found on the Division of Medicaid's
website.
4. Adjustments to the PPS
rate for the increase or decrease in scope of services are reflected in the PPS
rate for services provided in the calendar year following the calendar year in
which the change in scope of services took place. The revised PPS rate
generally cannot exceed the cost per visit from the most recent audited cost
report.
5. The RHC PPS rate will
not be adjusted solely for a change in ownership status between freestanding
and provider-based.
H.
Cost Reports
1. All RHCs must submit to the
Division of Medicaid a copy of their Medicare cost report for information
purposes using the appropriate Medicare forms postmarked on or before the last
day of the fifth (5) month following the close of its Medicare cost-reporting
year. All filing requirements shall be the same as for Title XVIII. When the
due date of the cost report falls on a weekend or State of Mississippi or
federal holiday, the cost report is due on the following business day.
Extensions of time for filing cost reports will not be granted by the Division
of Medicaid except for those supported by written notification of the extension
granted by Title XVIII. Cost reports must be prepared in accordance with the
State Plan for reimbursement of RHCs. The RHC's cost report should include
information on all satellite RHCs.
2. If the Medicare cost report is not
received within thirty (30) days of the due date, payment of claims will be
suspended until receipt of the required report. This penalty can only be waived
by the Executive Director of the Division of Medicaid.
3. An RHC that does not file a Medicare cost
report within six (6) calendar months after the close of its Medicare cost
reporting year may be subject to cancellation of its provider agreement at the
Division of Medicaid's discretion.
I. Medicaid payments are not be made to any
organization prior to the date of approval and execution of a valid Medicaid
provider agreement.
J. The Division
of Medicaid reimburses an outside laboratory for laboratory services not listed
in Miss. Admin. Code Part 212, Rule
1.2.C. separate from the PPS
rate.
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