Wyo. Code R. 048-0037-37
Medicaid
Chapter 37: Federally Qualified Health Center (FQHC) & Rural Health Clinics (RHC)
Effective Date: 02/12/2002 to 01/06/2015
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.37.02122002
This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W.S. § 42-4-101 et seq and the Wyoming Administrative Procedures Act at W. S. § 16-3-101 et seq.
(a) This Chapter shall apply to and govern Medicaid reimbursement of services provided in FQHCs and RHCs on or after January 1, 2001. The provisions contained in Chapter 26 of the Wyoming Medicaid Rules shall be subordinate to the provisions of this Chapter.
(b) The Department may issue Provider Manuals, Provider Bulletins, or both, to providers and/or other affected parties to interpret the provisions of this Chapter. Such Provider Manuals and Provider Bulletins shall be consistent with and reflect the policies contained in this Chapter. The provisions contained in Provider Manuals or Provider Bulletins shall be subordinate to the provisions of this Chapter.
(a) Terminology. Except as otherwise specified, the terminology used in this Chapter is the standard terminology and has the standard meaning used in accounting, health care, Medicaid and Medicare.
(b) General methodology. In accordance with Title VII, Section 702 of Pub. L. 106-554, codified at 42 U.S.C. § 1396a(aa) the Department reimburses FQHCs and RHCs for covered services using a prospective payment system based on the facility's base period costs, per visit, inflated forward using the Medicare economic index, and adjusted for changes in services.
(c) Unless otherwise specified, the incorporation by reference of any external standard is intended to be the incorporation of that standard as it is in effect on the effective date of this Chapter, including any applicable amendments, corrections, or revisions, but excluding any subsequent amendments or changes.
(a) 'Allowable costs.' Medicare allowable costs as determined pursuant to 42 U.S.C. § 1395(f), except as otherwise specified by this Chapter. Allowable costs and calculations of payments pursuant to this Chapter shall not be adjusted because of changes that result from a Medicare appeal or reopening.
(b) 'Baseline rate.' The rate established using the base period for a facility.
(c) 'Base period.' Facility fiscal years 1999 and 2000; If a facility provided services for only one fiscal year, that year will be used.
(d) 'Base period allowable costs.' The reasonable costs which are related to providing covered services during the base period as determined pursuant to 42 U.S.C. § 1396a(aa)(2), which is incorporated by this reference, and any regulations promulgated thereunder. Graduate medical education costs are allowable costs for qualifying facilities and shall be determined pursuant to 42 CFR § 405.2468(f), which is incorporated by this reference, except that the calculation shall be based on the facility's Medicaid costs rather than Medicare costs.
(e) 'Certified.' Approved by the survey agency as in compliance with applicable statutes and rules.
(f) 'Chapter 1.' Chapter 1, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid rules.
(g) 'Chapter 3.' Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.
(h) 'Chapter 4.' Chapter 4, Third Party Liability, of the Wyoming Medicaid Rules.
(i) 'Chapter 16.' Chapter 16, Medicaid Program Integrity, of the Wyoming Medicaid Rules.
(j) 'Chapter 39.' Chapter 39, Recovery of Excess Payments, of the Wyoming Medicaid Rules.
(k) 'Claim.' A request by a provider for Medicaid payment for covered services provided to a recipient.
(l) 'CMS.' The Center for Medicare and Medicaid Services of the United States Department of Health and Human Services, its agent, designee or successor.
(m) 'Cost report.' A cost report prepared and submitted in conformance with Medicare requirements. 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. 'Cost report' includes any supplemental request by the Department for additional information relating to the facility's costs.
(bb) 'Generally accepted auditing standards (GAAS).' Auditing standards, practices and procedures established by the American Institute of Certified Public Accountants.
(cc) 'HHS.' The United States Department of Health and Human Services, its agent, designee or successor.
(dd) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act and/or the Wyoming Medical Assistance and Services Act. 'Medicaid' includes any successor or replacement program enacted by Congress and/or the Wyoming Legislature.
(ee) 'Medicaid allowable costs.' Medicaid program costs as determined from Medicare cost reports that have been submitted to and audited by the Medicare Fiscal Intermediary. Medicaid allowable costs and calculations of payments shall not be adjusted because of changes that result from a Medicare appeal or reopening.
(ff) 'Medicaid allowable payment.' The per visit rate determined pursuant to Sections 9 and 10.
(gg) 'MFCU.' The Medicaid Fraud Control Unit of the Wyoming Attorney General's Office, its agent, designee, or successor.
(hh) 'Medically necessary' or 'medical necessity.' A service that is:
(i) Consistent with the recipient's diagnosis or condition;
(ii) Recognized as the prevailing standard or current practice among the provider's peer group; and
(iii) Rendered in response to a life-threatening condition or pain; to treat an injury, illness or infection; to treat a condition that could result in physical or mental disability; to care for a mother and child through the maternity period; or to achieve a level of physical or mental function which is consistent with prevailing community standards; or is a preventive pharmaceutical service.
(ii) 'Medical records.' All documents, in whatever form, in the possession of or subject to the control of a facility which describe the recipient's diagnosis, condition or treatment, including, but not limited to, the plan of care for the recipient.
(jj) 'Medicare.' The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.
(kk) 'Medicare economic index (MEI).' 'Medicare economic index for primary care services (MEI)' as defined in 42 U.S.C. § 1396a(aa)(3)(A), which definition is incorporated by this reference.
(ll) 'New provider.' A facility that qualified as an FQHC or RHC after September 30, 1999, and served Medicare or Medicaid patients during either year of the base period, or a facility that qualified as an FQHC or RHC after September 30, 2000.
(mm) 'Overpayments.' 'Overpayments' as defined in Chapter 39, which definition is incorporated by this reference.
(nn) 'Patient.' An individual who receives services at an FQHC or an RHC.
(oo) 'Provider.' A provider as defined by Chapter 3, Section 3(y), which definition is incorporated by this reference.
(pp) 'Rate.' A facility's Medicaid allowable payment.
(qq) 'Recipient.' A person who has been determined eligible for Medicaid.
(rr) 'Rural health center (RHC).' 'Rural health center (RHC)' as defined in 42 U.S.C. § 1396d(l)(1), which definition is incorporated by this reference.
(ss) 'RHC fiscal year.' The twelve-month period used by an RHC for accounting and tax purposes.
(tt) 'Rural health center services ('RHC services).' 'Rural health center services (RHC services)' as defined in 42 U.S.C. § 1396d(l)(1), which definition is incorporated by this reference.
(uu) 'Scope of service changes.' A change in the type, intensity, duration and/or 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.
(vv) 'Settled cost report.' A facility's cost report:
(i) Which has been submitted to Medicare in accordance with Medicare standards and procedures;
(ii) Which has been cost settled by the Medicare intermediary using Medicare principles of cost reimbursement;
(iii) For which a notice of program reimbursement has been issued; and
(iv) For which a notice of Medicaid program reimbursement has been issued.
(v) A cost report is settled notwithstanding a request to reopen.
(ww) 'Services.' FQHC services or RHC services.
(xx) 'State fiscal year.' The twelve-month period beginning each July 1st and ending the following June 30th.
(yy) 'Survey agency.' The Office of Health Care Quality of the Department, its agent, designee or successor, or a comparable agency in another state.
(zz) 'Third party liability.' Third party liability as determined pursuant to Chapter 4, which is incorporated by this reference.
(aaa) 'Visit.' A face-to-face encounter between a recipient and a professional staff member at a facility.
Section 5. Provider Participation.
(a) Payments only to providers. No facility, which furnishes services to a recipient, shall receive Medicaid funds unless the facility is certified, has signed a provider agreement, and is enrolled.
(b) Compliance with Chapter 3. A facility which wishes to receive Medicaid reimbursement for services furnished to a recipient must meet the provider participation requirements of Chapter 3, Sections 4 through 6, which are incorporated by this reference.
Section 6. Provider Records. A provider must comply with Chapter 3, Section 7, which is incorporated by this reference.
Section 7. Verification of recipient data. A provider must comply with Chapter 3, Section 8, which is incorporated by this reference.
Section 8. Medicaid allowable payment for services furnished before January 1, 2001. The Department reimburses for covered services provided to a recipient in an FQHC or an RHC using the methodology specified in the State Plan in effect as of December 31, 2000.
Section 9. Interim Medicaid allowable payment for services furnished on or after January 1, 2001, and before October 1, 2001.
(a) Interim Medicaid allowable payment. A facility shall receive an interim payment pursuant to Section 8.
(b) After the effective date of this Chapter, each facility's Interim Medicaid allowable payment shall be retroactively adjusted to January 1, 2001, to conform to the Medicaid allowable payment determined pursuant to Section 10.
Section 10. Medicaid allowable payment for services furnished on or after January 1, 2001.
(a) In General. The Department reimburses for covered services provided to recipients in an FQHC or an RHC using a prospective payment rate determined pursuant to this Chapter.
(b) The Department shall establish a separate payment rate for each facility. 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 facility for the facility's 1999 and 2000 fiscal years. This per visit cost shall be calculated using Medicaid allowable costs from the most recently settled cost reports from those fiscal years.
(ii) The Medicaid baseline rate for facilities with 1999 and 2000 facility fiscal year data shall be determined by calculating a per visit rate (total allowable costs divided by total patient visits) for facility fiscal year 1999 and facility fiscal year 2000; adding the two rates together; and dividing the sum by two.
(iii) The Medicaid baseline rate for facilities with only 2000 facility fiscal year data shall be determined by calculating a per visit rate (total allowable costs divided by total patient visits) for facility fiscal year 2000.
(iv) Scope of service changes for baseline rate.
(A) A facility 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; and
(II) The reasonableness of the facility's costs.
(C) The Department may request that the facility provide additional information to document the change in service. The information must be provided before the Department is obligated to consider the facility's request.
(v) Determination of baseline rate. The per visit rate calculated pursuant to Section 10(b)(iii), as adjusted for changes in scope of service pursuant to Section 10(b)(iv), shall be the facility'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 facility's most recently settled cost report, unless the cost report has been submitted, but not settled. In such circumstances, the Department shall use the facility'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 facility'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 reimburse the facility for any underpayment or recover any overpayment.
(ii) A change in a facility's rate pursuant to this subsection shall not affect any averages or arrays.
(d) Annual revision of Medicaid allowable payment. 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 4th calendar quarter in the Federal Register or posted at the CMS Health Care Indicators website.
(ii) The provider's Medicaid allowable payment shall be adjusted to reflect any increase or decrease in the scope of services furnished by the facility during the facility's fiscal year. The provisions of paragraph 10(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 10(d) 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 an FQHC or RHC after September 30, 1999, shall be equal to 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. 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 facility shall submit a financial information worksheet, in the form and manner specified by the Department, which:
(A) In the case of an existing facility, reports the facility'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 facility, estimates the facility's cost for its next fiscal year, the number of patients the facility expects to serve during that period, and the services which the facility expects to offer during that period.
(ii) Using the information provided pursuant to paragraph (i), the Department shall establish an interim rate based on the facility's reported or estimated Medicaid allowable costs.
(b) The rate determined pursuant to (a) shall remain in effect until the facility has submitted a cost report for one facility fiscal year, at which time the facility's rate shall be recalculated pursuant to this Chapter, except that the facility's base period shall be its first fiscal year during which the facility provided Medicaid services.
(i) If the rate was unreasonably low, the Department shall retroactively reimburse the facility for its Medicaid allowable costs.
(ii) If the rate was unreasonably high, the Department shall recoup the amount in excess of the facility's Medicaid allowable costs
(a) The Medicaid allowable payment for out-of-state facilities 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 facility's rate.
(a) Submission of claims. Claims for which third-party liability exists shall be submitted in accordance with Chapter 4, which is incorporated by this reference.
(b) Medicaid payment. The Medicaid payment for a claim for which third party liability exists shall be the difference between the Medicaid allowable payment and the third party payment. In no case shall the Medicaid payment exceed the payment otherwise allowable pursuant to this Chapter.
Section 14. Submission and Payment of claims. The submission and payment of claims shall be pursuant to the provisions of Chapter 3, which are incorporated by this reference.
Section 15. Recovery of excess payments or overpayments.
(a) The Department may recover excess payments pursuant to Chapter 39, which is incorporated by this reference.
(b) The Department may recover overpayments pursuant to Chapter 16, which is incorporated by this reference.
Section 16. Audits.
(a) The Department or CMS may audit a provider’s financial records or medical records at any time to determine whether the provider has received excess payments or overpayments. An audit may be a desk review or a field audit.
(b) The Department or CMS may perform audits through employees, agents, or through a third party. Audits shall be performed in accordance with generally accepted auditing standards.
(c) Disallowances. The Department shall recover excess payments or overpayments pursuant to Section 16.
(d) Reporting audit results. If at anytime during a financial audit or a medical audit, the Department discovers evidence suggesting fraud or abuse by a provider, that evidence, in addition to the Department’s final audit report regarding that provider, shall be referred to the MFCU.
Section 17. Reconsideration. A provider may request that the Department reconsider a decision to recover excess payments or overpayments. The request for reconsideration, the reconsideration, and any administrative hearing shall be pursuant to the reconsideration provisions of Chapter 3, which are incorporated by this reference.
Section 18. Disposition of recovered funds. The Department shall dispose of recovered funds pursuant to the provisions of Chapter 16, which provisions are incorporated by this reference.
Section 19. Interpretation of Chapter.
(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 20. Superseding effect. This Chapter supersedes all prior rules or policy statements issued by the Department, including Provider Manuals and Provider Bulletins, which are inconsistent with this Chapter.
Section 21. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in full force and effect.