D.C. Mun. Regs. tit. 29, r. 29-4510

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-4510 - ALLOWABLE COSTS

4510.1

The standards established in this section are to provide guidance in determining whether certain cost items will be recognized as allowable costs incurred by a FQHC in furnishing primary care, behavioral health, diagnostic and preventive dental services, and comprehensive dental services regardless of the applicable payment methodology. In the absence or specific instructions or guidelines, each FQHC shall follow the Medicare reasonable cost principles set forth in 45 CFR § 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards and 42 CFR § 413 Principles of Reasonable Cost Reimbursement and instructions set forth in the Medicare Provider Reimbursement Manual.

4510.2

Allowable costs, to the extent they are reasonable, necessary and related to patient care shall include but are not limited to the following:

(a) Compensation for the services rendered by each health care professional listed in Subsections 4507.2, 4508.2, 4505.15 and 4506.16 and other supporting health care professionals including but not limited to registered nurses, licensed practical nurses, nurse aides, medical assistants, physician's assistants, technicians, etc.;

(b) Compensation for services for supervising health care professionals described in Subsections 4507.2, 4508.2, 4505.15 and 4506.16;

(c) Costs of services and supplies incident to the provision of services as described in (f) of this subsection;

(d) Administrative and capital costs that are incurred in furnishing primary care, behavioral health services, diagnostic and preventive dental services, and comprehensive dental services, including clinic administration, subject to the limitation set forth in this section;

(e) Enabling services that support an individual's management of his or her health and social service needs or improve the FQHC's ability to treat the individual, including:

(1) Health education and promotion services including assisting the individual in developing a self- management plan, executing the plan through self- monitoring and management skills, educating the individual on accessing care in appropriate settings and making healthy lifestyle and wellness choices; connecting the individual to peer and/or recovery supports including self- help and advocacy groups; and providing support for improving an individual's social network. These services shall be provided by health educators, with or without specific degrees in this area, family planning specialists, HIV specialists, or other professionals who provide information about health conditions and guidance about appropriate use of health services;

(2) Translation and interpretation services during an encounter at the FQHC. These services are provided by staff whose full time or dedicated time is devoted to translation and/or interpretation services or by an outside licensed translation and interpretation service provider. Any portion of the time of a physician, nurse, medical assistant, or other support and administrative staff who provides interpretation or translation during the course of his or her other billable activities shall not be included;

(3) Referrals to providers of medical services (including specialty referral when medically indicated) and other health-related services (including substance abuse and mental health services). Such services shall not be reimbursed separately as enabling services where such referrals are provided during the course of other billable treatment activities;

(4) Eligibility assistance services designed to assist individuals in establishing eligibility for and gaining access to Federal, State and District programs that provide or financially support the provision of medical related services;

(5) Health literacy;

(6) Outreach services to identify potential patients and clients and/or facilitate access or referral of potential health center patients to available health center services, including reminders for upcoming events, brochures and social services;

(7) Care coordination, which consists of services designed to organize person-centered care activities and information sharing among those involved in the clinical and social aspects of an individual's care to achieve safer and more effective healthcare and improved health outcomes. These services shall be provided by individuals trained as, and with specific titles of care coordinators, case managers, referral coordinators, or other titles such as nurses, social workers, and other professional staff who are specifically allocated to care coordination during assigned hours but not when these services are an integral part of their other duties such as providing direct patient care;

(8) Staff cost related to quality improvement, data analytics, and compliance; and

(9) Training for health care professionals for the provision of health care services.

(f) Incidental services and supplies that are integral, although incidental, to the diagnostic or treatment components of the services described in Subsections 4505.7, 4506.8, 4507.1(a), and 4508.1 which shall include but are not limited to the following:

(1) Lactation consultation, education and support services that are provided by health care professionals described in Subsection 4507.1(4)(ii);

(2) Medical services ordinarily rendered by an FQHC staff person such as taking patient history, blood pressure measurement or temperatures, and changing dressings;

(3) Medical supplies, equipment or other disposable products such as gauze, bandages, and wrist braces;

(4) Administration of drugs or medication treatments, including administration of contraceptive treatments, that are delivered during a primary care visit, not including the cost of the drugs and medications;

(5) Immunizations;

(6) Electrocardiograms;

(7) Office-based laboratory screenings or tests performed by FQHC employees in conjunction with an encounter, which shall not include lab work performed by an external laboratory or x-ray provider. These services include but are not limited to stool testing for occult blood, dipstick urinalysis, cholesterol screening, and tuberculosis testing for high-risk beneficiaries; and

(8) Hardware and software systems, including implementation services, used to facilitate patient record-keeping and related services to support implementation.

4510.3

For the purposes of determining allowable and reasonable costs in the purchase of goods and services from a related party, each FQHC shall identify all related parties.

4510.4

A related party is any individual, organization or entity who currently or within the previous five (5) years has had a business relationship with the owner or operator of an FQHC, either directly or indirectly, or is related by marriage of birth to the owner or operator of the FQHC, or who has a relationship arising from common ownership or control.

4510.5

The cost claimed on the cost report for services, facilities and supplies furnished by a related party shall not exceed the lower of:

(a) The cost incurred by the related party; or

(b) The price of comparable services, facilities, or supplies generally available.

4510.6

Administrative and capital costs shall be allocated and included in determining the total allowable costs for primary care services and behavioral health services.

4510.7

Administrative and general overhead costs shall consist of overhead facility costs as described in Sub section 4510.8 and administrative costs as described in Subsection 4510.9.

4510.8

Capital and facility costs shall include but not be limited to:

(a) Rent;

(b) Insurance;

(c) Interest on mortgages or loans;

(d) Utilities;

(e) Depreciation on buildings;

(f) Depreciation on equipment;

(g) Maintenance, including janitorial services;

(h) Building security services; and

(i) Real estate and property taxes.

4510.9

Administrative costs shall include but not be limited to:

(a) Administrative Salaries (i.e., salary expenditures related to the administrative work of a FQHC);

(b) Fringe benefits and payroll taxes of personnel described in paragraph (a) of this subsection;

(c) Depreciation on office equipment;

(d) Office supplies;

(e) Legal expenses;

(f) Accounting expenses;

(g) Training costs of administrative personnel for the provision of health care services;

(h) Telephone expense; and

(i) Hardware and software, including implementation costs, not related to patient record keeping.

4510.10

Administrative costs shall be subject to a ceiling of twenty percent (20%) as described in Sections 4503, 4504, 4505 and 4506. Costs in excess of the ceiling shall not be included in allowable costs.

D.C. Mun. Regs. tit. 29, r. 29-4510

Final Rulemaking published at 64 DCR 907 (2/2/2018)