Utah Admin. Code R414-9-7 - Scope of Service Changes (SSC)

(1) A provider who wants an SSC rate consideration must provide required documentation, meet SSC requirements, and have a qualifying event. The provider must email documentation to MedicaidHealthCenter@utah.gov.

(2) Documentation must clearly detail the change in type, intensity, duration, and amount of services, and include additional documentation that the FQHC or RHC supports the request. An FQHC or RHC must also submit to the Department the Medicaid scope of services application.

(a) FQHCs or RHCs that submit retrospective cost information must submit a completed change in scope worksheet showing:

(i) costs by service type and totals with data from the most recently completed Medicare cost report;

(ii) calculation of total allowable billable visits with data from the Medicare cost report and detail of additional visits;

(iii) detail of costs and visits associated with the qualifying event; and

(iv) any additional cost information or documentation that the Department requests.

(b) For health centers that submit prospective cost information, a completed SSC worksheet showing:

(i) a budget for a future 12-month period that includes any prospective qualifying events;

(ii) a projection of total allowable billable visits;

(iii) documentation of additional costs associated with prospective qualifying events, with a description of how the estimates were determined to be reasonable; and

(iv) a narrative description of each qualifying event in the change in SSC.

(3) For health centers applying for their first SSC before January 1, 2025, qualifying events may include items from the previous eight years.

(4) For health centers applying for their first SSC after January 1, 2025, qualifying events may include items from the previous two years.

(5) For health centers that have already done an SSC, only qualifying events since the earlier approved change in scope may be submitted for consideration.

(6) The Department calculates an incremental cost for each visit by dividing incremental costs by total visits. The new PPS rate is calculated by adding the incremental cost for each visit to the current PPS rate. The Department applies other appropriate adjustments in accordance with the Medicaid State Plan.

(7) It is the responsibility of the FQHC or RHC to notify the Department of any increases or decreases in costs.

(8) General requirements for FQHCs or RHCs to complete an SSC change include the following:

(a) The Department must receive a complete request documentation package at least six months before the end of the FQHC and RHC fiscal year to change the next fiscal year's PPS rate. When an FQHC or RHC submits an SSC change without complete documentation, the request is returned without processing. The FQHC or RHC provider shall resubmit the entire request including the additional documentation. The date, in which a complete request with supporting documentation is received, is the submission date used for the SSC change.

(b) The effective date is the first day of the provider's fiscal year following the year in which the SSC is submitted, subject to the terms of Subsection (8)(a).

(c) The requested rate change from the SSC costs must exceed a 5% increase or decrease threshold from the current PPS Medicaid rate.

(d) The FQHC or RHC may not submit a request for an SSC change more than every two years. An exception may be allowed for the following:

(i) an HRSA-approved new access point; or

(ii) the SSC exceeds a 10% increase or decrease threshold.

(e) The Department shall deny requests to review SSC changes that go back more than eight years. Effective January 1, 2025, the Department shall deny requests to review SSC changes that go back more than two years.

(9) An FQHC or RHC must have a qualifying event to trigger an SSC change. The qualifying event may result in either an increase or decrease in services. The following are considered qualifying events if covered by Medicaid:

(a) increasing primary care and medical specialties such as cardiology and dermatology;

(b) adding or supplementing case management or care coordination for non-billable services;

(c) adding preventive dental or restorative dental surgery;

(d) x-ray that includes ultrasound, provided directly, but not through referral arrangement;

(e) medication-assisted treatment;

(f) behavioral health;

(i) adding behavioral health services and providers;

(ii) supplementing care team with behavioral health staff, such as community health workers and behaviorists who may not generate additional billable visits;

(g) substance use disorder treatment services;

(h) lab tests, in addition to rapid and CLIA-waived, including coronavirus rapid tests;

(i) obstetrical and gynecological services;

(j) distinct staff and services for social determinants of health interventions, such as non-medical factors that impact quality of life risks and health outcomes, which include food insecurities, housing instability, transportation barriers, and literacy levels;

(k) enabling services such as interpretation, financial counseling, diabetes, and education;

(l) providing direct optometry services;

(m) adding new or certified staff for chronic pain management;

(n) including clinical pharmacists;

(o) chiropractic care;

(p) physical therapy;

(q) complementary and alternative medicine; and

(r) an amendment to the Medicaid State Plan to remove a service that an FQHC or RHC has previously offered.

(10) Any increase or decrease in services under Subsection (9) may be a qualifying event.

(11) FQHC or RHCs that have a change in intensity, amount, or duration of the following services, if covered by Medicaid, would be considered a qualifying event:

(a) the provision of additional listed services or the deletion of a new type of service;

(b) telehealth;

(c) first-time implementation of an electronic medical record;

(d) new electronic medical record modules;

(e) remote patient monitoring;

(f) regulatory compliance through new rules and building a compliance infrastructure;

(g) population changes among groups such as the homeless, the elderly, and those with human immunodeficiency virus, acquired immunodeficiency syndrome, and other chronic diseases;

(h) an HRSA-approved change in the scope of project such as the addition of a new site;

(i) a mix of healthcare providers that includes treatment from a psychiatrist, infectious disease specialist, or other healthcare provider;

(j) public health emergencies;

(k) changing capital costs from a remodel, relocation, or establishing a new site;

(l) a new technological service or infrastructure that does not replace the current one; and

(m) costs associated with a teaching health center.

(12) The Department considers only the net cost of an SSC for payment if an SSC change is otherwise reimbursed.

Notes

Utah Admin. Code R414-9-7

Adopted by Utah State Bulletin Number 2023-12, effective 6/12/2023