Wyo. Code R. 048-0037-37
Medicaid
Chapter 37: Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)
Effective Date: 09/06/2018 to 08/11/2023
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.37.09062018
Section 1. Authority. This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at Wyoming Statutes §§ 42-4-101 through -121.
(a) This Chapter has been adopted to establish Medicaid reimbursement of services provided in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), as defined in 42 U.S.C. § 1396a(bb).
(b) The requirements of Title XIX of the Social Security Act, 42 C.F.R. §§ 440.20(b) and 405.2468(f), 42 U.S.C. § 1396a(bb), and the Medicaid State Plan also apply to Medicaid and are incorporated by this reference.
Section 3. Definitions. Except as otherwise specified in Chapter 1 or as defined in this Section, the terminology used in this Chapter is the standard terminology and has the standard meaning used in healthcare, Medicaid, and Medicare.
(a) 'Base period.' 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.
Section 4. General Methodology. 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.
(a) 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, per visit, inflated forward using the Medicare economic index, and adjusted for changes in services.
Section 5. Provider Participation. In order to receive Medicaid reimbursement for furnishing services to a client, a FQHC or RHC shall be an enrolled Medicaid provider in accordance with Wyoming Medicaid Rules.
Section 6. Medicaid Allowable Payment for Services Furnished Before January 1, 2001. The Department shall reimburse for covered services provided to a
client in a FQHC or RHC using the methodology specified in the State Plan in effect as of December 31, 2000.
(a) Interim Medicaid allowable payment. A FQHC or RHC shall receive an interim payment pursuant to Section 6 of this Chapter.
(b) After the effective date of this Chapter, each FQHC’s and RHC’s Interim Medicaid allowable payment shall be retroactively adjusted to January 1, 2001, to conform to the Medicaid allowable payment determined pursuant to Section 8 of this Chapter.
(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. This per visit cost shall be calculated using Medicaid allowable costs from the most recently settled cost reports from those fiscal years. Visits shall be face-to-face encounters between a client and a professional staff member at a facility.
(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 year 1999 and fiscal year 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) A 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) Provide a report, in the form and manner specified by the Department 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 Section 8(b)(ii) or (iii) of this Chapter, as adjusted for changes in scope of service pursuant to Section 8(b)(iv) of this Chapter, 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.
(c) The Department shall base all cost and rate calculations on a FQHC’s or RHC’s most recently settled cost report, unless the cost report has been submitted, but not settled. In such circumstances, the Department shall use the FQHC’s or RHC’s cost report as filed. If a provider or prospective provider does not participate in Medicare and does not submit a Medicare cost report, it shall submit cost information to the Department in the form and manner specified by the Department.
(i) If a cost or rate calculation is based on an as filed 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 adjust the rate prospectively only 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 or arrays.
(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 Medicare Economic Index (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 (https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareProgramRatesStats/MarketBasketData.html).
(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 8(b)(iv) of this Chapter shall apply to any proposed rate changes based on a change in services.
(iii) The payment established pursuant to Section 8(d) of this Chapter shall be effective for the calendar year beginning January 1 following the determination of the new rate.
(a) The Medicaid allowable payment for a provider that qualifies as a FQHC or RHC after September 30, 1999, shall be equal to one hundred percent (100%) of the reasonable costs used in calculating the rates of FQHCs or RHCs with similar caseloads located in the State during the same FQHC or RHC fiscal year. If there are no FQHCs or RHCs located in Wyoming with a similar caseload, then the Department shall calculate the rate for the new FQHC or RHC based on projected costs after applying tests of reasonableness.
(i) The FQHC or RHC shall submit a financial information worksheet, in the form and manner specified by the Department, which:
(A) In the case of an existing FQHC or RHC, reports the FQHC's or RHC's costs for its most recently completed fiscal year, the number of patient visits during that period, the services furnished to those patients, and any pending changes in services; or
(B) In the case of a new FQHC or RHC, estimates the FQHC's or RHC's cost for its next fiscal year, the number of patients the FQHC or RHC expects to serve during that period, and the services which the FQHC or RHC expects to offer during that period.
(ii) Using the information provided pursuant to Section 9(a)(i), the
Department shall establish an interim rate based on the FQHC's or RHC's reported or estimated Medicaid allowable costs.
(b) The rate determined pursuant to Section 9(a) shall remain in effect until the FQHC or RHC has submitted a cost report for one (1) FQHC or RHC fiscal year, at which time the FQHC's or RHC's rate shall be recalculated pursuant to this Chapter, except that the FQHC's or RHC's base period shall be its first (1st) 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 the State 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.
Section 11. Third Party Liability. Third Party Liability shall be subject to the requirements of Chapter 35.
Section 12. Submission and Payment of Claims. The submission and payment of claims shall be pursuant to Chapter 3.
Section 13. Recovery of Overpayments. The Department shall recover overpayments pursuant to Chapter 16.
Section 14. Reconsideration. A provider may request reconsideration of the decision to recover overpayments pursuant to Chapter 16.
Section 15. Audits. Audits shall be subject to the provisions of Chapter 16.
Section 16. Disposition of Recovered Funds. The Department shall dispose of recovered funds pursuant to the provisions of Chapter 16.
(a) The order in which the provisions of this Chapter appear is not to be construed to mean that any one provision is more or less important than any other provision.
(b) The text of this Chapter shall control the titles of its various provisions.
Section 18. Superseding Effect. This Chapter supersedes all prior rules or policy statements issued by the Department, including manuals and bulletins, which are inconsistent with this Chapter.
Section 19. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in effect.
(a) For any code, standard, rule, or regulation incorporated by reference in these rules:
(i) The Department of Health has determined that incorporation of the full text in these rules would be cumbersome or inefficient given the length or nature of the rules.
(ii) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection (b) of this section; and
(iii) The incorporated code, standard, rule, or regulation is maintained at the Department of Health and is available for public inspection and copying at cost at the same location.
(b) Each item is incorporated by reference and is further identified as follows:
(i) Referenced in Section 2 of this Chapter is Title XIX of the Social Security Act, which is incorporated as of the effective date of this Chapter and can be found at https://www.ssa.gov/.
(ii) Referenced in Sections 2 and 4 of this Chapter is 42 C.F.R. § 440.20(b), which is incorporated as of the effective date of this Chapter and can be found at http://www.ecfr.gov.
(iii) Referenced in Sections 2 and 3 of this Chapter is 42 C.F.R. § 405.2468(f), which is incorporated as of the effective date of this Chapter and can be found at http://www.ecfr.gov.
(iv) Referenced in Sections 2, 3, 4 of this Chapter is 42 U.S.C. § 1396a, which is incorporated as of the effective date of this Chapter and can be found at http://uscode.house.gov/.
(v) Referenced in Section 8 of this Chapter is the Medicare Economic
Index, which is incorporated as of the effective date of this Chapter and can be found at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareProgramRatesStats/MarketBasketData.html.