Ohio Admin. Code 5160-28-06.1 - FQHC and RHC services: limits on a per-visit payment amount (PVPA) determined on the basis of a cost report for an FQHC PPS service

(A) Allowable costs are calculated in accordance with the instructions for the federally qualified health center (FQHC) cost report. Certain restrictions apply:
(1) Costs related to direct inpatient care are not allowable.
(2) Procedures or items that are not PPS services are not allowable.
(3) The straight-line method of computing depreciation is used for all depreciable assets.
(4) The cost claimed for services, facilities, and supplies furnished by a related organization cannot exceed the lesser of two figures:
(a) The cost to the related organization; or
(b) The price of comparable services, facilities, or supplies that are generally available in the competitive marketplace.
(5) Total allowable administrative and general overhead costs cannot exceed thirty-five per cent of the costs of the services to which they are applied. Of these costs, not more than thirty thousand dollars are allowable annually as recruitment cost incurred by a provider of FQHC medical service.
(B) Limits are established by applying tests of reasonableness to the allowable costs.
(1) For each PPS service except transportation, a limit is established by dividing the allowable cost by the greater of two figures:
(a) The total number of visits; or
(b) The product of the actual number of direct hours worked by the professional and the applicable number of visits per hour from the following list:
(i) Physician services, per physician - 2.4;
(ii) Physician assistant or advanced practice registered nurse services, per practitioner - 1.2;
(iii) Dental services - 1.8;
(iv) Physical therapy services - 2.0;
(v) Behavioral health services or substance use disorder services - 0.7;
(vi) Speech pathology and audiology services - 1.8;
(vii) Podiatry services - 2.4;
(viii) Vision services - 1.9;
(ix) Chiropractor services - 2.4. and
(x) Occupational therapy services - 2.0;
(2) For transportation, a limit is established of twenty-five dollars per unit of service.
(C) A ceiling is established for each PPS service at one hundred twenty per cent of the statewide sixtieth percentile PVPA.
(D) The final PVPA for an FQHC PPS service is the least of the allowable cost, the limit, or the ceiling.

Replaces: 5160-28- 06.1


Ohio Admin. Code 5160-28-06.1
Effective: 7/1/2022
Five Year Review (FYR) Dates: 07/01/2027
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 10/25/2001, 07/01/2006, 10/01/2016

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