471 Neb. Admin. Code, ch. 29, § 004

Current through September 17, 2024

Section 471-29-004 - Prospective Payment System

004.01 Prospective Payment System Base Rates

The Prospective Payment System base rate will be computed as follows:

1. Combine reasonable costs from the FQHC fiscal year 1999 and 2000 cost reports; and

2. Divide the costs by the Total Adjusted Visits from the two fiscal year cost reports (Form HCFA- 222-92 Worksheet C, Part 1, Line 6; or Form HCFA- 2552-96 Worksheet M-3, Line 6).

Beginning October 1, 2001, the PPS base rate will be updated annually based on the Medicare Economic Index (MEI).

004.02 Rates for New Providers

The Department will establish rates for a new FQHC entering the program after 1999 as follows:

1. For the initial year, the interim rate will be the average PPS rate of all FQHCs in Nebraska. The interim rate will be retroactively settled based on the FQHC's initial cost report.

2. The FQHC's individual PPS base rate will be computed later, using its initial cost report.

3. The PPS base rate will be updated annually based on the Medicare Economic Index (MEI).

004.03 FQHC Managed Care Payments

FQHCs that provide services under a contract with a Medicaid managed care entity (MCE) will receive quarterly state supplemental payments for the cost of furnishing such services that are an estimate of the difference between the payment the FQHC receives from the MCE(s) and the payments the FQHC would have received under the PPS methodology.

29-004.03A At the end of each FQHC fiscal year, the Department will compare:

1. The total amount of supplemental and MCE payments received by the FQHC; to

2. The amount that the actual number of visits provided under the FQHC's contract with the MCE(s) would have yielded under the PPS methodology.

The Department will pay the FQHC the difference between item 1 and item 2 if the PPS amount exceeds the total amount of supplemental and MCE payments. The FQHC must refund the difference between item 1 and item 2 if the PPS payment is less than the total amount of the supplemental and MCE payments.

004.04 Non-FQHC Services

For non-FQHC services, NMAP will pay according to the Nebraska Medicaid Practitioners Fee Schedule.

004.05 Payment for Telehealth Services

Payment for telehealth services will be the Medicaid rate for the comparable in-person service. FQHC core services provided via telehealth technologies are not covered under the encounter rate.

29-004.05APayment for Telehealth Transmission Costs: Payment for telehealth transmission costs related to non-core services will be the lower of:

1. The provider's submitted charge; or

2. The maximum allowable amount.

The Department will pay for transmission costs for line charges when directly related to a covered telehealth service. The provider must be in compliance with the standards for real time, two way interactive audiovisual transmissions (see 471 NAC 1-006).

471 Neb. Admin. Code, ch. 29, § 004