Wyo. Code R. 048-0037-37
Medicaid
Chapter 37: Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)
Effective Date: 08/11/2023 to Current
Rule Type: Current Rules & Regulations
Reference Number: 048.0037.37.08112023
FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS
(a) The Wyoming Department of Health (Department) promulgates this Chapter pursuant to the Medical Assistance and Services Act at Wyoming Statutes 42-4-101 through -124.
(a) The Department adopts this Chapter to establish the Wyoming Medicaid requirements and reimbursement for services provided in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), as defined in 42 U.S.C. § 1396d(l)(2).
(b) This Chapter applies to all clients and providers for all Medicaid-covered services furnished in FQHCs and RHCs.
(c) The Department may issue manuals and bulletins to interpret this Chapter. Such manuals and bulletins shall be consistent with and reflect the rules contained in this Chapter. The provisions contained in manuals or bulletins shall be subordinate to this Chapter.
Section 3. Definitions. Except as otherwise specified in Wyoming Medicaid Rules Chapter 1, or as defined herein, the terminology used in this Chapter is the standard terminology and has the standard meaning used in healthcare, Medicaid, and Medicare.
(a) “Base period” means FQHC or RHC fiscal years 1999 and 2000; if a FQHC or RHC provided services for only one (1) fiscal year, that year shall be used as the “base period.”
(b) “Medicare Economic Index (MEI)” means the measure of practice cost inflation used to estimate annual changes in physicians’ operating costs and earnings levels.
(c) “Visit” means a face-to-face encounter between a FQHC or RHC client and a FQHC or RHC professional staff member for the purpose of providing FQHC or RHC services. Telehealth visits are considered face-to-face visits.
Section 4. Provider Enrollment and Participation. In order to receive Medicaid reimbursement for furnishing services to a client, a FQHC or RHC shall be an enrolled Medicaid provider and in compliance with requirements for Medicaid participation in accordance with Wyoming Medicaid Rules Chapter 3.
(a) FQHC and RHC reimbursable services are outpatient services that occur during an eligible visit and include:
(iii) Behavioral health services provided pursuant to Wyoming Medicaid Rules Chapter 13 by providers licensed to provide such services;
(iv) Preventive primary care services;
(v) Dental services;
(vi) Vision services;
(vii) Audiology services;
(b) The following services and supplies furnished as incidental to the provider’s services are included in the provider’s rate and are not billable as a stand-alone visit, even if the service is performed on a separate day from the original visit:
(i) Lab services;
(ii) Drugs and biologicals that cannot be self-administered;
(iii) Supplies;
(iv) Radiology;
(v) Diagnostic services;
(vi) Therapeutic services;
(vii) Outreach;
(viii) Case management;
(ix) Transportation;
(c) If services are furnished at a permanent site in more than one location, each site will be independently considered for approval as a provider, unless prior approval was granted by CMS to operate both locations under a single provider number. To be considered a satellite provider location both sites must share medical staff, office staff, and/or administrative staff.
(a) Base period allowable costs are considered to be reasonable costs which are related to providing covered services during the base period as determined pursuant to 42 U.S.C. 1396a(bb)(2). Graduate medical education costs shall be allowable costs for qualifying FQHCs and RHCs and shall be determined pursuant to 42 C.F.R. § 405.2468(f), except that the calculation shall be based on the FQHC’s or RHC’s Medicaid costs rather than Medicare costs.
(b) In accordance with 42 U.S.C. § 1396a(bb) the Department shall reimburse FQHCs and RHCs for covered services using a prospective payment system based on each FQHC’s or RHC’s base period costs for that calendar year, per visit, inflated forward using the MEI, and adjusted for changes in services.
(a) The Department shall reimburse for covered services provided to clients in a FQHC or RHC using a prospective payment rate determined pursuant to this Chapter.
(b) The Department shall establish a separate payment rate for each FQHC and RHC. The rate shall be determined using the base period Medicaid allowable costs, which are calculated as follows:
(i) The Department shall calculate a per visit cost for each FQHC and RHC for the FQHC's and RHC's 1999 and 2000 fiscal years. A fiscal year shall be the twelve (12) month period used by a FQHC or RHC for accounting and tax purposes.
(ii) The Medicaid baseline rate (rate established using the base period for each FQHC and RHC) with 1999 and 2000 fiscal year data shall be determined by calculating a per visit rate (total allowable costs divided by total patient visits) for fiscal years 1999 and 2000; adding the two (2) rates together; and dividing the sum by two (2).
(iii) The Medicaid baseline rate for each FQHC and RHC with only 2000 fiscal year data shall be determined by calculating a per visit rate (total allowable costs divided by total patient visits) for fiscal year 2000.
(iv) Scope of service changes for baseline rate.
(A) An FQHC or RHC which desires an adjustment to its baseline rate due to an increase or decrease in its scope of service shall:
(I) Notify the Department, in writing, of the increase or decrease; and
(II) Submit a settled Medicare Cost Report which documents the change in services and substantiates the costs associated with that change.
(B) The Department shall assess the information provided and shall determine if a rate change is warranted and the amount of any such change. Those determinations shall be based upon:
(I) The nature of the new or discontinued service regarding the type, intensity, duration, and amount of services. A change in the cost of a service is not considered in and of itself a change in the scope of services; and
(II) The reasonableness of the FQHC's or RHC's costs.
(C) The Department may request that the FQHC or RHC provide additional information to document the change in service. The information shall be provided before the Department is obligated to consider the FQHC's or RHC's request.
(v) The per visit rate calculated pursuant to this Section, as adjusted for changes in scope of service pursuant to this Section, shall be the FQHC's or RHC's baseline rate for services provided on or after January 1, 2001, and shall be the basis for future rate determinations.
(vi) For any FQHC or RHC that was not in operation during 1999 or 2000 fiscal years, refer to Section 7.
(c) The Department shall base all cost and rate calculations on a FQHC's or RHC's most recently settled Medicare Cost Report. If a settled Medicare Cost Report is not available, the Department shall use the FQHC's or RHC's Medicare Cost Report as filed.
(i) If a cost or rate calculation is based on an 'as filed' Medicare Cost Report, the Department shall recalculate the cost or rate within a reasonable time after the FQHC's or RHC's settled cost report becomes available. If the cost or rate based on an 'as filed' cost report is different from the cost or rate calculation based on the settled cost report, the Department shall only adjust the rate prospectively and shall not retroactively reimburse the FQHC or RHC for any underpayment or recover any overpayment.
(ii) A change in a FQHC's or RHC's rate pursuant to this subsection shall not affect any averages.
(d) The Department shall re-determine each provider's Medicaid allowable payment each Federal fiscal year beginning on or after October 1, 2001, as follows:
(i) The provider's Medicaid allowable payment in effect on October 1 of each year shall be adjusted by the percentage increase in the MEI as calculated using the annual data published in the fourth (4th) calendar quarter in the Federal Register or posted at the CMS Health Care Indicators website at https://www.cms.gov on the Market Basket Data updates page.
(ii) The provider's Medicaid allowable payment shall be adjusted prospectively to reflect any increase or decrease in the scope of services furnished by the FQHC or RHC during the FQHC's or RHC's fiscal year. The provisions of Section (b)(iv) shall apply to any proposed rate changes based on a change in services.
(iii) The payment established pursuant to Section 7(d) of this Chapter shall be effective for the calendar year beginning January 1 following the determination of the new rate.
(a) A provider that qualifies as a FQHC or RHC after September 30, 1999, must submit a settled or 'as filed' Medicare Cost Report to the Department, which will serve as the basis for the provider's rate calculation. Upon submission of a settled or an 'as filed' Medicare Cost Report a visit rate will be calculated as described by the cost formula in Section 7.
(b) If the FQHC or RHC does not have a settled or an 'as filed' Medicare Cost Report, the provider shall submit cost information to the Department for services previously provided indicating estimates for its next fiscal year and the number of patients and services it expects to offer during that period.
(c) The Medicaid allowable payment for a new provider shall be an interim visit rate equal to one hundred (100) percent of the reasonable costs used in calculating the rates of FQHCs or
RHCs with similar caseloads located in the state during the same facility fiscal year, adjusted by the percentage increase in MEI, as described by the cost formula in Section 7. Interim visit rates will be specific to each provider type: Independent RHCs, Hospital-based RHCs, and FQHCs.
(i) If there are no FQHCs or RHC's with similar caseloads, the Medicaid allowable payment for a new provider shall be an interim visit rate equal to the Medicaid statewide average visit rate for the calendar year, adjusted by the percentage increase in MEI, as described by the cost formula in Section 7. Interim visit rates will be specific to each provider type: Independent RHCs, Hospital-based RHCs, and FQHCs.
(d) The interim rate determined pursuant to subsection (c) shall remain in effect until the FQHC or RHC has submitted a settled Medicare Cost Report, at which time the FQHC's or RHC's rate shall be recalculated pursuant to Section 7, except that the new FQHC's or RHC's base period shall be its first fiscal year during which the FQHC or RHC provided Medicaid services. The Department shall not retroactively reimburse the FQHC or RHC for any underpayment or recover any overpayment based on changes in the calculated rate.
(a) The Medicaid allowable payment for out-of-state FQHCs and RHCs shall be the statewide average Medicaid allowable payment in effect in Wyoming as of October 1st of that year.
(b) The statewide average Medicaid allowable payment shall not be affected by a subsequent change in a FQHC's or RHC's rate.