C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-31, subsec. 144-101-II-31.07
FQHCs are reimbursed in accordance with the requirements of section 702 of the Benefits Improvement and Protection Act (BIPA) of 2000, including requirements for a Prospective Payment System.
Reimbursement is generally limited to one core service visit, and/or one ambulatory service visit per day. Reimbursement for a second core visit is also covered if the member has both an encounter with a physician, physician assistant, advanced nurse practitioner or visiting nurse, and in addition to that encounter, is seen on the same dayby a licensed clinical psychologist, clinical social worker, clinical professional counselor or a clinical nurse specialist licensed as an advanced practice clinical nurse specialist. An additional visit of any other kind will only be reimbursed for unforeseen circumstances as documented in the member's record. The goal remains to treat the whole individual during one visit.
Federally Qualified Health Centers may be reimbursed in excess of their core and additional (same day) visit rates when providing services delineated in the respective sections of the MaineCare Benefits Manual: Primary Care Case Management Services per Chapter VI, Section 1; and Chapter 1.
Any additional center visits that are required in the patient's treatment plan that do not qualify as center visits for reimbursement purposes are non-billable.
FQHCs have the option of obtaining a separate MaineCare provider billing number for the limited purpose of FFS billing and reimbursement for such services as x-ray, EKG, inpatient hospital visits and other Medicare defined non-FQHC services that are billable under Medicare Part B. If a center chooses to bill fee for service for Medicare defined non-FQHC services, it may not report costs related to these services on its MaineCare cost report.
Effective January 1, 2001, FQHCs will be reimbursed on the basis of 100% of the average of their reasonable costs of providing MaineCare-covered services during calendar years 1999 and 2000, adjusted to take into account any increase or decrease in the approved scope of services furnished during the provider's fiscal year 2001 (calculating the amount of payment on a per visit basis).
At the start of each subsequent year, beginning in CY 2002, each FQHC is entitled to the payment amount (on a per visit basis) to which the center was entitled under the Act in the previous fiscal year, inflated by the percentage increase in the Medicare Economic Index (MEI) for primary care services, and adjusted to take into account any increase or decrease fora MaineCare approved "change in scope of services."
Newly qualified FQHCs after state fiscal year 2017 will have initial payments (calculated on a per visit basis) established either by reference to payments to other centers in the same or adjacent areas with a similar caseload, or in the absence of such other centers, through cost reporting methods. Cost reports must accurately reflect the costs of the individual FQHC (i.e. may not be a consolidated report of multiple sites or organizations that is not able to distinguish FQHC costs). For each fiscal year following the initial year, payment shall be adjusted for MEI and approved "change in scope of services." This applies to each new FQHC site or location with a separate National Provider Identifier that is opening, regardless of affiliation to an existing organization, and regardless of previous service delivery.
FQHCs must submit their HRSA Scope of Project for the Fiscal Year 1999, or for their first year of operation for FQHCs approved after Fiscal Year 1999, plus any subsequent approved Plan of Project amendments.
A "change in the scope of services" refers to a change in the overall picture of a FQHC's services through a change in the type, intensity, duration and/or amount of services.
The following examples are offered as guidance to FQHCs to facilitate understanding of the types of changes that may be recognized as a "change in scope of services." These examples should not be interpreted as a definitive nor comprehensive delineation of the definition of "change of scope of services."
An increase or decrease in "scope of services" does notnecessarily result from any of the following (although some of these changes may occur in conjunction with a "change in scope of services"):
It is the FQHC's responsibility to notify the Department of any "change in the scope of services" and provide proper documentation to support the rate change request. The FQHC must submit either at least six (6) months of actual cost data for changes that have already taken place, or twelve (12) months of projected costs for anticipated changes.
When an FQHC submits projected costs for an anticipated change in the scope of services that amounts to a PPS rate change that is greater than or equal to five percent (5%), the Department may request data from the FQHC when at least six (6) months of actual data becomes available for a rate review and adjustment as determined by the Department. The FQHC must also submit a narrative describing the change. Requests for a rate adjustment based on a prior change must be received no later than one hundred and fifty (150) days after the FQHC's fiscal year end in which the "change in scope of services" occurred. The Department will respond with a decision to a rate adjustment request within sixty (60) days of receiving a completed application. An application is considered complete when the Department confirms that it has received all the information needed to process the application.
Adjustments to the PPS rate for the increase or decrease in scope of services will be reflected in the PPS rate beginning with services provided the first day of the month immediately following either the date the Department approves the "change in scope of services" adjustment or the date an anticipated change will begin, whichever is later.
For members who are eligible for both Medicare and MaineCare services, MaineCare will provide reimbursement to providers as follows:
After Medicare has completed its payment, the provider may bill MaineCare and MaineCare will pay the remaining amount up to the Medicare rate (including co-insurance), for Medicare only services.
For services covered by Medicare, after Medicare has completed its payment, the provider may bill MaineCare and MaineCare will pay the remaining amount (including co-insurance) up to the MaineCare rate. For services only covered by MaineCare, MaineCare will pay all MaineCare expenses.
After Medicare has completed its payment, the provider may bill MaineCare and MaineCare will pay for covered MaineCare services provided by MaineCare providers but only to the extent that the MaineCare rate exceeds any Medicare payment for any service covered by both Medicare and MaineCare.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-31, subsec. 144-101-II-31.07