D.C. Mun. Regs. tit. 29, r. 29-4512

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

Rule 29-4512 - REIMBURSEMENT FOR NEW PROVIDERS

4512.1

Each new provider seeking Medicaid reimbursement as an FQHC shall meet all of the requirements set forth in Section 4500.

4512.2

Reimbursement for services furnished by a new provider shall be determined in accordance the PPS methodology set forth in this section.

4512.3

The PPS rate for services furnished during the first year of operation shall be calculated as of the first day of the District's fiscal year in which the FQHC commences operations, and shall be equal to the average of the PPS rates paid to other FQHCs located in the same geographical area with a similar caseload.

4512.4

After the first year of operation, the FQHC shall submit a cost report to DHCF. DHCF shall audit the cost report in accordance with the standards set forth in Sections 4510 and 4511 and establish a PPS for each of the following four categories:

(a) Primary care services covered under Section 1905(a)(2) of the Social Security Act as set forth in Section 4507;

(b) Behavioral health services covered under Section 1905(a)(2) of the Social Security Act as set forth in Section 4508;

(c) Preventive and diagnostic dental services covered under Section 1905(a)(2) of the Social Security Act as set forth in Subsection 4505.7; and

(d) Comprehensive dental services covered under Section 1905(a)(2) of the Social Security Act as set forth in Subsection 4506.7.

4512.5

The PPS shall be calculated for each category described in Subsections 4512.4(a) through 4512.4(d) by taking the sum of the FQHC's audited allowable cost for the applicable category, including related administrative and capital costs, and dividing it by the total number of eligible encounters for that category.

4512.6

The PPS rate described in Subsection 4512.5 shall remain in effect until all provider rates are rebased in accordance with Section 4516. After rebasing the FQHC shall be have the option of electing an APM rate in accordance with the procedures set forth in Section 4501.

4512.7

In addition to the PPS rate described in this section, the FQHC shall be entitled to receive a supplemental wrap-around payment as described in Subsections 4502.6 through 4502.7.

4512.8

Each new FQHC provider seeking Medicaid reimbursement shall:

(a) Obtain a separate National Provider Identification number; and

(b) Be screened and enrolled in the Medicaid program pursuant to the requirements set forth in Chapter 94 of Title 29 DCMR.

4512.9

Each new FQHC shall only seek Medicaid reimbursement for services provided consistent with the services described in Sections 4505 - 4508 in accordance with Section 1905(a)(2) of the Social Security Act.

4512.10

If an FQHC discontinues operations, either as a facility or at one of its sites, the FQHC shall notify DHCF in writing at least ninety days (90) prior to discontinuing services.

4512.11

The new provider will be allowed one encounter on the same day for each of the categories described in Subsection 4512.4(a), (b), and either (c) or (d), consistent with the requirements set forth under Subsections 4505.12 and 4506.13.

D.C. Mun. Regs. tit. 29, r. 29-4512

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