| (4) The effective rate for APPS - The effective rate
is the rate paid to the FQHC for the FQHC's fiscal year. The effective
rate shall be updated by the rate of change in the MEI plus (0.5)
percent for each of the FQHC's fiscal years since the setting of its
final base rate. If the increase in an FQHC's costs is greater than
the MEI plus (0.5) percent for APPS, an FQHC may request an adjustment
of its effective rate as described in paragraph (6) of this subsection.
The effective rate shall be calculated at the start of each FQHC's
fiscal year and shall be applied prospectively for that fiscal year.
The effective rate for PPS is described in subsection (a)(1) of this
section.
(5) PPS and APPS reimbursement methodology selection
is determined as follows:
(A) Each new in-state FQHC will receive a letter from
HHSC upon enrollment as a new provider along with the Federally Qualified
Health Centers (FQHC) Prospective Payment System Form. This form must
be signed by an authorized representative and returned to HHSC within
thirty (30) days of the enrollment letter date. The form must indicate
the selection as either the PPS or APPS reimbursement methodology.
If HHSC does not receive the form within the specified time requirement,
HHSC will select the PPS reimbursement methodology for this provider.
For a provider that fails to return the form selecting the APPS reimbursement
methodology, the provider may submit a written request along with
the Federally Qualified Health Centers (FQHC) Prospective Payment
System Form selecting the APPS reimbursement methodology. Upon approval
by HHSC, the new selection will be effective the first day of the
provider's next fiscal year.
(B) Each out-of-state FQHCs will receive the PPS reimbursement
methodology. Out-of-state FQHCs may not select the APPS reimbursement
methodology. HHSC will compute an effective rate based on reasonable
costs provided by the FQHC on its most recent Medicare cost report,
pursuant to paragraph (8)(A) and (B) of this subsection. The effective
rate will reflect the rate that would have been calculated for an
in-state FQHC based on the approved scope of services that an in-state
FQHC could provide in Texas.
(C) When HHSC makes a change to the PPS or APPS reimbursement
methodology, HHSC may require FQHCs to reselect the PPS or APPS reimbursement
methodology, in accordance with the requirements of subparagraph (A)
of this paragraph.
(6) A change of the effective rate is determined as
follows:
(A) An adjustment, as described in paragraph (10)(C)
of this subsection, will be made to the effective rate if the FQHC
can show that it is operating in an efficient manner as defined in
paragraph (7)(B) of this subsection, or show that the adjustment is
warranted due to a change in scope as defined in paragraph (7)(A)
of this subsection.
(B) HHSC also may adjust the effective rate of an FQHC
on its own initiative, in accordance with paragraph (10)(D) of this
subsection, if it is determined that a change of scope has occurred
and an adjustment to the effective rate as defined in paragraph (7)
of this subsection is warranted based on the audit of the cost report
described in paragraph (8)(C) of this subsection.
(7) Any request to adjust an effective rate must be
accompanied by documentation showing that the FQHC is operating in
an efficient manner or that it has had a change in scope. A change
in scope provided by an FQHC includes the addition or deletion of
a service or a change in the magnitude, intensity or character of
services currently offered by an FQHC or one of the FQHC's sites.
(A) A change in scope includes:
(i) an increase in service intensity attributable to
changes in the types of patients served, including but not limited
to, patients with HIV/AIDS, the homeless, the elderly, migrants, those
with other chronic diseases or special populations;
(ii) any changes in services or provider mix provided
by an FQHC or one of its sites;
(iii) changes in operating costs that have occurred
during the fiscal year and which are attributable to capital expenditures,
including new service facilities or regulatory compliance;
(iv) changes in operating costs attributable to changes
in technology or medical practices at the FQHC;
(v) indirect medical education adjustments and a direct
graduate medical education payment that reflects the costs of providing
teaching services to interns and residents; or
(vi) any changes in scope approved by the Health Resources
and Service Administration (HRSA).
(B) Operating in an efficient manner includes:
(i) showing that the FQHC has implemented an outcome-based
delivery system that includes prevention and chronic disease management.
Prevention includes, but is not limited to, programs such as immunizations
and medical screens. Disease Management must include, but not be limited
to, programs such as those for diabetes, cardiovascular conditions,
and asthma that can demonstrate an overall improvement in patient
outcome;
(ii) paying employees' salaries that do not exceed
the rates of payment for similar positions in the area, taking into
account experience and training as determined by the Texas Workforce
Commission;
(iii) providing fringe benefits to its employees that
do not exceed fifteen percent (15%) of the FQHC's total costs;
(iv) implementing cost saving measures for its pharmacy
and medical supplies expenditures by engaging in group purchasing;
and
(v) employing the Medicare concept of a "prudent buyer"
in purchasing its contracted medical services.
(8) Cost report forms and worksheets are required as
follows:
(A) As-Filed Medicare Cost Report. The As-Filed Medicare
Cost Report includes:
(i) CMS form 222-92 Independent Rural Health Clinic/Freestanding
and Federally Qualified Health Center Worksheet, including the HCFA
339 Form.
(I) Worksheet S part 1 - Statistical Data;
(II) Worksheet S part 2 - Certification By Officer
or Administrator;
(III) Worksheet S part 3 - Statistical Data for Clinics
Filing Under Consolidated Cost Reporting;
(IV) Worksheet A page 1 - Reclassification and Adjustment
of Trial Balance of Expenses;
(V) Worksheet A page 2 - Reclassification and Adjustment
of Trial Balance of Expenses;
(VI) Worksheet A-1 - Reclassifications;
(VII) Worksheet A-2 - Adjustments to Expenses;
(VIII) Worksheet A-2-1, Parts I to III - Statement
of Cost of Services from Related Organizations;
(IX) Worksheet B part I and II - Visits and Overhead
Cost for RHC/FQHC Services; and
(X) Worksheet C part I and II - Determination of Medicare
Reimbursement.
(ii) Texas Medicaid Supplemental Worksheets.
(I) Determination of FQHC Cost Based Rate;
(II) Exhibit 1 - Determination of FQHC Medicaid Reimbursable
Cost - Rate Worksheet;
(III) Exhibit 2 - Visit Reconciliation - Employed Providers;
and
(IV) Exhibit 3 - Visit Reconciliation - Contract Service
Providers.
(iii) Trial Balance with account titles. If the provider's
Trial Balance has only account numbers, a Chart of Accounts will need
to accompany the Trial Balance.
(iv) A mapping of the Trial Balance that shows the
tracing of each Trial Balance account to a line and column on Worksheet
A pages 1 and 2.
(v) Documentation supporting the provider's reclassification
and adjustment entries.
(vi) A Schedule of Depreciation of depreciable assets.
(vii) A listing of all satellites, if applicable.
(viii) Federal Grant Award notices or changes in scope
approved by HRSA.
(ix) All items must be complete and accurate.
(B) Final Audited Medicare Cost Report. In-state providers
must file the final audited cost report received from Medicare, as
required in paragraph (9) of this subsection. The final audited Medicare
cost report includes:
(i) A copy of the final audited CMS form 222-92 Independent
Rural Health Clinic/Freestanding and Federally Qualified Health Center
Worksheets, including the HCFA 339 Form filed with Medicare.
(ii) Texas Medicaid Supplemental Worksheets.
(I) Determination of FQHC Cost Based Rate;
(II) Exhibit 1 - Determination of FQHC Medicaid Reimbursable
Cost - Rate Worksheet;
(III) Exhibit 2 - Visit Reconciliation - Employed Providers;
and
Cont'd... |
