Bill Text: CA AB858 | 2015-2016 | Regular Session | Enrolled
Bill Title: Medi-Cal: federally qualified health centers and rural health clinics.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Vetoed) 2016-01-15 - Consideration of Governor's veto stricken from file. [AB858 Detail]
Download: California-2015-AB858-Enrolled.html
BILL NUMBER: AB 858 ENROLLED
BILL TEXT
PASSED THE SENATE SEPTEMBER 9, 2015
PASSED THE ASSEMBLY SEPTEMBER 10, 2015
AMENDED IN SENATE SEPTEMBER 4, 2015
AMENDED IN SENATE AUGUST 31, 2015
AMENDED IN SENATE JULY 1, 2015
AMENDED IN ASSEMBLY MAY 28, 2015
AMENDED IN ASSEMBLY APRIL 21, 2015
INTRODUCED BY Assembly Member Wood
(Coauthor: Senator McGuire)
FEBRUARY 26, 2015
An act to amend Section 14132.100 of the Welfare and Institutions
Code, relating to Medi-Cal.
LEGISLATIVE COUNSEL'S DIGEST
AB 858, Wood. Medi-Cal: federally qualified health centers and
rural health clinics.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services,
pursuant to which medical benefits are provided to public assistance
recipients and certain other low-income persons. Existing law
provides that federally qualified health center (FQHC) services and
rural health clinic (RHC) services, as defined, are covered benefits
under the Medi-Cal program, to be reimbursed, to the extent that
federal financial participation is obtained, to providers on a
per-visit basis. "Visit" is defined as a face-to-face encounter
between a patient of an FQHC or RHC and specified health care
professionals. Existing law allows an FQHC or RHC to apply for an
adjustment to its per-visit rate based on a change in the scope of
services it provides.
This bill would also include a marriage and family therapist
within those health care professionals covered under the definition
of "visit." The bill would require an FQHC or RHC that currently
includes the cost of services of a marriage and family therapist for
the purposes of establishing its FQHC or RHC rate to apply to the
department for an adjustment to its per-visit rate, and, after the
rate adjustment has been approved by the department, would require
the FQHC or RHC to bill these services as a separate visit, as
specified. The bill would require an FQHC or RHC that does not
provide the services of a marriage and family therapist, and later
elects to add these services, to process the addition of these
services as a change in scope of service.
This bill would incorporate additional changes to Section
14132.100 of the Welfare and Institutions Code made by this bill and
SB 610 to take effect if both bills are enacted and this bill is
enacted last.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 14132.100 of the Welfare and Institutions Code
is amended to read:
14132.100. (a) The federally qualified health center services
described in Section 1396d(a)(2)(C) of Title 42 of the United States
Code are covered benefits.
(b) The rural health clinic services described in Section 1396d(a)
(2)(B) of Title 42 of the United States Code are covered benefits.
(c) Federally qualified health center services and rural health
clinic services shall be reimbursed on a per-visit basis in
accordance with the definition of "visit" set forth in subdivision
(g).
(d) Effective October 1, 2004, and on each October 1, thereafter,
until no longer required by federal law, federally qualified health
center (FQHC) and rural health clinic (RHC) per-visit rates shall be
increased by the Medicare Economic Index applicable to primary care
services in the manner provided for in Section 1396a(bb)(3)(A) of
Title 42 of the United States Code. Prior to January 1, 2004, FQHC
and RHC per-visit rates shall be adjusted by the Medicare Economic
Index in accordance with the methodology set forth in the state plan
in effect on October 1, 2001.
(e) (1) An FQHC or RHC may apply for an adjustment to its
per-visit rate based on a change in the scope of services provided by
the FQHC or RHC. Rate changes based on a change in the scope of
services provided by an FQHC or RHC shall be evaluated in accordance
with Medicare reasonable cost principles, as set forth in Part 413
(commencing with Section 413.1) of Title 42 of the Code of Federal
Regulations, or its successor.
(2) Subject to the conditions set forth in subparagraphs (A) to
(D), inclusive, of paragraph (3), a change in scope of service means
any of the following:
(A) The addition of a new FQHC or RHC service that is not
incorporated in the baseline prospective payment system (PPS) rate,
or a deletion of an FQHC or RHC service that is incorporated in the
baseline PPS rate.
(B) A change in service due to amended regulatory requirements or
rules.
(C) A change in service resulting from relocating or remodeling an
FQHC or RHC.
(D) A change in types of services due to a change in applicable
technology and medical practice utilized by the center or clinic.
(E) An increase in service intensity attributable to changes in
the types of patients served, including, but not limited to,
populations with HIV or AIDS, or other chronic diseases, or homeless,
elderly, migrant, or other special populations.
(F) Any changes in any of the services described in subdivision
(a) or (b), or in the provider mix of an FQHC or RHC or one of its
sites.
(G) Changes in operating costs attributable to capital
expenditures associated with a modification of the scope of any of
the services described in subdivision (a) or (b), including new or
expanded service facilities, regulatory compliance, or changes in
technology or medical practices at the center or clinic.
(H) Indirect medical education adjustments and a direct graduate
medical education payment that reflects the costs of providing
teaching services to interns and residents.
(I) Any changes in the scope of a project approved by the federal
Health Resources and Services Administration (HRSA).
(3) No change in costs shall, in and of itself, be considered a
scope-of-service change unless all of the following apply:
(A) The increase or decrease in cost is attributable to an
increase or decrease in the scope of services defined in subdivisions
(a) and (b), as applicable.
(B) The cost is allowable under Medicare reasonable cost
principles set forth in Part 413 (commencing with Section 413) of
Subchapter B of Chapter 4 of Title 42 of the Code of Federal
Regulations, or its successor.
(C) The change in the scope of services is a change in the type,
intensity, duration, or amount of services, or any combination
thereof.
(D) The net change in the FQHC's or RHC's rate equals or exceeds
1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs
that filed consolidated cost reports for multiple sites to establish
the initial prospective payment reimbursement rate, the 1.75-percent
threshold shall be applied to the average per-visit rate of all sites
for the purposes of calculating the cost associated with a
scope-of-service change. "Net change" means the per-visit rate change
attributable to the cumulative effect of all increases and decreases
for a particular fiscal year.
(4) An FQHC or RHC may submit requests for scope-of-service
changes once per fiscal year, only within 90 days following the
beginning of the FQHC's or RHC's fiscal year. Any approved increase
or decrease in the provider's rate shall be retroactive to the
beginning of the FQHC's or RHC's fiscal year in which the request is
submitted.
(5) An FQHC or RHC shall submit a scope-of-service rate change
request within 90 days of the beginning of any FQHC or RHC fiscal
year occurring after the effective date of this section, if, during
the FQHC's or RHC's prior fiscal year, the FQHC or RHC experienced a
decrease in the scope of services provided that the FQHC or RHC
either knew or should have known would have resulted in a
significantly lower per-visit rate. If an FQHC or RHC discontinues
providing onsite pharmacy or dental services, it shall submit a
scope-of-service rate change request within 90 days of the beginning
of the following fiscal year. The rate change shall be effective as
provided for in paragraph (4). As used in this paragraph,
"significantly lower" means an average per-visit rate decrease in
excess of 2.5 percent.
(6) Notwithstanding paragraph (4), if the approved
scope-of-service change or changes were initially implemented on or
after the first day of an FQHC's or RHC's fiscal year ending in
calendar year 2001, but before the adoption and issuance of written
instructions for applying for a scope-of-service change, the adjusted
reimbursement rate for that scope-of-service change shall be made
retroactive to the date the scope-of-service change was initially
implemented. Scope-of-service changes under this paragraph shall be
required to be submitted within the later of 150 days after the
adoption and issuance of the written instructions by the department,
or 150 days after the end of the FQHC's or RHC's fiscal year ending
in 2003.
(7) All references in this subdivision to "fiscal year" shall be
construed to be references to the fiscal year of the individual FQHC
or RHC, as the case may be.
(f) (1) An FQHC or RHC may request a supplemental payment if
extraordinary circumstances beyond the control of the FQHC or RHC
occur after December 31, 2001, and PPS payments are insufficient due
to these extraordinary circumstances. Supplemental payments arising
from extraordinary circumstances under this subdivision shall be
solely and exclusively within the discretion of the department and
shall not be subject to subdivision ( l ). These
supplemental payments shall be determined separately from the
scope-of-service adjustments described in subdivision (e).
Extraordinary circumstances include, but are not limited to, acts of
nature, changes in applicable requirements in the Health and Safety
Code, changes in applicable licensure requirements, and changes in
applicable rules or regulations. Mere inflation of costs alone,
absent extraordinary circumstances, shall not be grounds for
supplemental payment. If an FQHC's or RHC's PPS rate is sufficient to
cover its overall costs, including those associated with the
extraordinary circumstances, then a supplemental payment is not
warranted.
(2) The department shall accept requests for supplemental payment
at any time throughout the prospective payment rate year.
(3) Requests for supplemental payments shall be submitted in
writing to the department and shall set forth the reasons for the
request. Each request shall be accompanied by sufficient
documentation to enable the department to act upon the request.
Documentation shall include the data necessary to demonstrate that
the circumstances for which supplemental payment is requested meet
the requirements set forth in this section. Documentation shall
include all of the following:
(A) A presentation of data to demonstrate reasons for the FQHC's
or RHC's request for a supplemental payment.
(B) Documentation showing the cost implications. The cost impact
shall be material and significant, two hundred thousand dollars
($200,000) or 1 percent of a facility's total costs, whichever is
less.
(4) A request shall be submitted for each affected year.
(5) Amounts granted for supplemental payment requests shall be
paid as lump-sum amounts for those years and not as revised PPS
rates, and shall be repaid by the FQHC or RHC to the extent that it
is not expended for the specified purposes.
(6) The department shall notify the provider of the department's
discretionary decision in writing.
(g) (1) An FQHC or RHC "visit" means a face-to-face encounter
between an FQHC or RHC patient and a physician, physician assistant,
nurse practitioner, certified nurse-midwife, clinical psychologist,
licensed clinical social worker, or a visiting nurse. For purposes of
this section, "physician" shall be interpreted in a manner
consistent with the Centers for Medicare and Medicaid Services'
Medicare Rural Health Clinic and Federally Qualified Health Center
Manual (Publication 27), or its successor, only to the extent that it
defines the professionals whose services are reimbursable on a
per-visit basis and not as to the types of services that these
professionals may render during these visits and shall include a
medical doctor, osteopath, podiatrist, dentist, optometrist, and
chiropractor. A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a comprehensive perinatal
practitioner, as defined in Section 51179.7 of Title 22 of the
California Code of Regulations, providing comprehensive perinatal
services, a four-hour day of attendance at an adult day health care
center, and any other provider identified in the state plan's
definition of an FQHC or RHC visit.
(2) (A) A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a dental hygienist, a dental
hygienist in alternative practice, or a marriage and family
therapist.
(B) Notwithstanding subdivision (e), an FQHC or RHC that currently
includes the cost of the services of a dental hygienist in
alternative practice, or a marriage and family therapist, for the
purposes of establishing its FQHC or RHC rate shall apply for an
adjustment to its per-visit rate, and, after the rate adjustment has
been approved by the department, shall bill these services as a
separate visit. However, multiple encounters with dental
professionals or marriage and family therapists that take place on
the same day shall constitute a single visit. The department shall
develop the appropriate forms to determine which FQHC's or RHC's
rates shall be adjusted and to facilitate the calculation of the
adjusted rates. An FQHC's or RHC's application for, or the department'
s approval of, a rate adjustment pursuant to this subparagraph shall
not constitute a change in scope of service within the meaning of
subdivision (e). An FQHC or RHC that applies for an adjustment to its
rate pursuant to this subparagraph may continue to bill for all
other FQHC or RHC visits at its existing per-visit rate, subject to
reconciliation, until the rate adjustment for visits between an FQHC
or RHC patient and a dental hygienist, a dental hygienist in
alternative practice, or a marriage and family therapist has been
approved. Any approved increase or decrease in the provider's rate
shall be made within six months after the date of receipt of the
department's rate adjustment forms pursuant to this subparagraph and
shall be retroactive to the beginning of the fiscal year in which the
FQHC or RHC submits the request, but in no case shall the effective
date be earlier than January 1, 2008.
(C) An FQHC or RHC that does not provide dental hygienist, dental
hygienist in alternative practice, or marriage and family therapist
services, and later elects to add these services, shall process the
addition of these services as a change in scope of service pursuant
to subdivision (e).
(h) If FQHC or RHC services are partially reimbursed by a
third-party payer, such as a managed care entity (as defined in
Section 1396u-2(a)(1)(B) of Title 42 of the United States Code), the
Medicare program, or the Child Health and Disability Prevention
(CHDP) program, the department shall reimburse an FQHC or RHC for the
difference between its per-visit PPS rate and receipts from other
plans or programs on a contract-by-contract basis and not in the
aggregate, and may not include managed care financial incentive
payments that are required by federal law to be excluded from the
calculation.
(i) (1) An entity that first qualifies as an FQHC or RHC in the
year 2001 or later, a newly licensed facility at a new location added
to an existing FQHC or RHC, and any entity that is an existing FQHC
or RHC that is relocated to a new site shall each have its
reimbursement rate established in accordance with one of the
following methods, as selected by the FQHC or RHC:
(A) The rate may be calculated on a per-visit basis in an amount
that is equal to the average of the per-visit rates of three
comparable FQHCs or RHCs located in the same or adjacent area with a
similar caseload.
(B) In the absence of three comparable FQHCs or RHCs with a
similar caseload, the rate may be calculated on a per-visit basis in
an amount that is equal to the average of the per-visit rates of
three comparable FQHCs or RHCs located in the same or an adjacent
service area, or in a reasonably similar geographic area with respect
to relevant social, health care, and economic characteristics.
(C) At a new entity's one-time election, the department shall
establish a reimbursement rate, calculated on a per-visit basis, that
is equal to 100 percent of the projected allowable costs to the FQHC
or RHC of furnishing FQHC or RHC services during the first 12 months
of operation as an FQHC or RHC. After the first 12-month period, the
projected per-visit rate shall be increased by the Medicare Economic
Index then in effect. The projected allowable costs for the first 12
months shall be cost settled and the prospective payment
reimbursement rate shall be adjusted based on actual and allowable
cost per visit.
(D) The department may adopt any further and additional methods of
setting reimbursement rates for newly qualified FQHCs or RHCs as are
consistent with Section 1396a(bb)(4) of Title 42 of the United
States Code.
(2) In order for an FQHC or RHC to establish the comparability of
its caseload for purposes of subparagraph (A) or (B) of paragraph
(1), the department shall require that the FQHC or RHC submit its
most recent annual utilization report as submitted to the Office of
Statewide Health Planning and Development, unless the FQHC or RHC was
not required to file an annual utilization report. FQHCs or RHCs
that have experienced changes in their services or caseload
subsequent to the filing of the annual utilization report may submit
to the department a completed report in the format applicable to the
prior calendar year. FQHCs or RHCs that have not previously submitted
an annual utilization report shall submit to the department a
completed report in the format applicable to the prior calendar year.
The FQHC or RHC shall not be required to submit the annual
utilization report for the comparable FQHCs or RHCs to the
department, but shall be required to identify the comparable FQHCs or
RHCs.
(3) The rate for any newly qualified entity set forth under this
subdivision shall be effective retroactively to the later of the date
that the entity was first qualified by the applicable federal agency
as an FQHC or RHC, the date a new facility at a new location was
added to an existing FQHC or RHC, or the date on which an existing
FQHC or RHC was relocated to a new site. The FQHC or RHC shall be
permitted to continue billing for Medi-Cal covered benefits on a
fee-for-service basis under its existing provider number until it is
informed of its FQHC or RHC enrollment approval, and the department
shall reconcile the difference between the fee-for-service payments
and the FQHC's or RHC's prospective payment rate at that time.
(j) Visits occurring at an intermittent clinic site, as defined in
subdivision (h) of Section 1206 of the Health and Safety Code, of an
existing FQHC or RHC, or in a mobile unit as defined by paragraph
(2) of subdivision (b) of Section 1765.105 of the Health and Safety
Code, shall be billed by and reimbursed at the same rate as the FQHC
or RHC establishing the intermittent clinic site or the mobile unit,
subject to the right of the FQHC or RHC to request a scope-of-service
adjustment to the rate.
(k) An FQHC or RHC may elect to have pharmacy or dental services
reimbursed on a fee-for-service basis, utilizing the current fee
schedules established for those services. These costs shall be
adjusted out of the FQHC's or RHC's clinic base rate as
scope-of-service changes. An FQHC or RHC that reverses its election
under this subdivision shall revert to its prior rate, subject to an
increase to account for all Medicare Economic Index increases
occurring during the intervening time period, and subject to any
increase or decrease associated with applicable scope-of-service
adjustments as provided in subdivision (e).
( l ) FQHCs and RHCs may appeal a grievance or
complaint concerning ratesetting, scope-of-service changes, and
settlement of cost report audits, in the manner prescribed by Section
14171. The rights and remedies provided under this subdivision are
cumulative to the rights and remedies available under all other
provisions of law of this state.
(m) The department shall, no later than March 30, 2008, promptly
seek all necessary federal approvals in order to implement this
section, including any amendments to the state plan. To the extent
that any element or requirement of this section is not approved, the
department shall submit a request to the federal Centers for Medicare
and Medicaid Services for any waivers that would be necessary to
implement this section.
(n) The department shall implement this section only to the extent
that federal financial participation is obtained.
SEC. 1.5. Section 14132.100 of the Welfare and Institutions Code
is amended to read:
14132.100. (a) The federally qualified health center services
described in Section 1396d(a)(2)(C) of Title 42 of the United States
Code are covered benefits.
(b) The rural health clinic services described in Section 1396d(a)
(2)(B) of Title 42 of the United States Code are covered benefits.
(c) Federally qualified health center services and rural health
clinic services shall be reimbursed on a per-visit basis in
accordance with the definition of "visit" set forth in subdivision
(g).
(d) Effective October 1, 2004, and on each October 1 thereafter,
until no longer required by federal law, federally qualified health
center (FQHC) and rural health clinic (RHC) per-visit rates shall be
increased by the Medicare Economic Index applicable to primary care
services in the manner provided for in Section 1396a(bb)(3)(A) of
Title 42 of the United States Code. Prior to January 1, 2004, FQHC
and RHC per-visit rates shall be adjusted by the Medicare Economic
Index in accordance with the methodology set forth in the state plan
in effect on October 1, 2001.
(e) (1) An FQHC or RHC may apply for an adjustment to its
per-visit rate based on a change in the scope of services provided by
the FQHC or RHC. Rate changes based on a change in the scope of
services provided by an FQHC or RHC shall be evaluated in accordance
with Medicare reasonable cost principles, as set forth in Part 413
(commencing with Section 413.1) of Title 42 of the Code of Federal
Regulations, or its successor.
(2) Subject to the conditions set forth in subparagraphs (A) to
(D), inclusive, of paragraph (3), a change in scope of service means
any of the following:
(A) The addition of a new FQHC or RHC service that is not
incorporated in the baseline prospective payment system (PPS) rate,
or a deletion of an FQHC or RHC service that is incorporated in the
baseline PPS rate.
(B) A change in service due to amended regulatory requirements or
rules.
(C) A change in service resulting from relocating or remodeling an
FQHC or RHC.
(D) A change in types of services due to a change in applicable
technology and medical practice utilized by the center or clinic.
(E) An increase in service intensity attributable to changes in
the types of patients served, including, but not limited to,
populations with HIV or AIDS, or other chronic diseases, or homeless,
elderly, migrant, or other special populations.
(F) Any changes in any of the services described in subdivision
(a) or (b), or in the provider mix of an FQHC or RHC or one of its
sites.
(G) Changes in operating costs attributable to capital
expenditures associated with a modification of the scope of any of
the services described in subdivision (a) or (b), including new or
expanded service facilities, regulatory compliance, or changes in
technology or medical practices at the center or clinic.
(H) Indirect medical education adjustments and a direct graduate
medical education payment that reflects the costs of providing
teaching services to interns and residents.
(I) Any changes in the scope of a project approved by the federal
Health Resources and Services Administration (HRSA).
(3) No change in costs shall, in and of itself, be considered a
scope-of-service change unless all of the following apply:
(A) The increase or decrease in cost is attributable to an
increase or decrease in the scope of services defined in subdivisions
(a) and (b), as applicable.
(B) The cost is allowable under Medicare reasonable cost
principles set forth in Part 413 (commencing with Section 413) of
Subchapter B of Chapter 4 of Title 42 of the Code of Federal
Regulations, or its successor.
(C) The change in the scope of services is a change in the type,
intensity, duration, or amount of services, or any combination
thereof.
(D) The net change in the FQHC's or RHC's rate equals or exceeds
1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs
that filed consolidated cost reports for multiple sites to establish
the initial prospective payment reimbursement rate, the 1.75-percent
threshold shall be applied to the average per-visit rate of all sites
for the purposes of calculating the cost associated with a
scope-of-service change. "Net change" means the per-visit rate change
attributable to the cumulative effect of all increases and decreases
for a particular fiscal year.
(4) An FQHC or RHC may submit requests for scope-of-service
changes once per fiscal year, only within 90 days following the
beginning of the FQHC's or RHC's fiscal year. Any approved increase
or decrease in the provider's rate shall be retroactive to the
beginning of the FQHC's or RHC's fiscal year in which the request is
submitted.
(5) An FQHC or RHC shall submit a scope-of-service rate change
request within 90 days after the beginning of any FQHC or RHC fiscal
year occurring after the effective date of this section, if, during
the FQHC's or RHC's prior fiscal year, the FQHC or RHC experienced a
decrease in the scope of services provided that the FQHC or RHC
either knew or should have known would have resulted in a
significantly lower per-visit rate. If an FQHC or RHC discontinues
providing onsite pharmacy or dental services, it shall submit a
scope-of-service rate change request within 90 days after the
beginning of the following fiscal year. The rate change shall be
effective as provided for in paragraph (4). As used in this
paragraph, "significantly lower" means an average per-visit rate
decrease in excess of 2.5 percent.
(6) (A) The department shall conduct an initial review of a
scope-of-service rate change request within 30 days after submission
by an FQHC or RHC.
(B) If the department determines that additional information is
necessary to finalize a new rate, the department shall notify the
FQHC or RHC, no later than the 31st day after submission. The
notification shall state the reason or reasons the submitted
information is insufficient and shall request submission of
supplemental information from the FQHC or RHC.
(C) Within one year after receiving a submission that it
determines to be complete, the department shall finalize the FQHC's
or RHC's rate and shall update the provider master file within 10
business days.
(7) Notwithstanding paragraph (4), if the approved
scope-of-service change or changes were initially implemented on or
after the first day of an FQHC's or RHC's fiscal year ending in
calendar year 2001, but before the adoption and issuance of written
instructions for applying for a scope-of-service change, the adjusted
reimbursement rate for that scope-of-service change shall be made
retroactive to the date the scope-of-service change was initially
implemented. Scope-of-service changes under this paragraph shall be
required to be submitted within the later of 150 days after the
adoption and issuance of the written instructions by the department,
or 150 days after the end of the FQHC's or RHC's fiscal year ending
in 2003.
(8) All references in this subdivision to "fiscal year" shall be
construed to be references to the fiscal year of the individual FQHC
or RHC, as the case may be.
(f) (1) An FQHC or RHC may request a supplemental payment if
extraordinary circumstances beyond the control of the FQHC or RHC
occur after December 31, 2001, and PPS payments are insufficient due
to these extraordinary circumstances. Supplemental payments arising
from extraordinary circumstances under this subdivision shall be
solely and exclusively within the discretion of the department and
shall not be subject to subdivision ( l ). These
supplemental payments shall be determined separately from the
scope-of-service adjustments described in subdivision (e).
Extraordinary circumstances include, but are not limited to, acts of
nature, changes in applicable requirements in the Health and Safety
Code, changes in applicable licensure requirements, and changes in
applicable rules or regulations. Mere inflation of costs alone,
absent extraordinary circumstances, shall not be grounds for
supplemental payment. If an FQHC's or RHC's PPS rate is sufficient to
cover its overall costs, including those associated with the
extraordinary circumstances, then a supplemental payment is not
warranted.
(2) The department shall accept requests for
supplemental payment at any time throughout the prospective payment
rate year.
(3) Requests for supplemental payments shall be submitted in
writing to the department and shall set forth the reasons for the
request. Each request shall be accompanied by sufficient
documentation to enable the department to act upon the request.
Documentation shall include the data necessary to demonstrate that
the circumstances for which supplemental payment is requested meet
the requirements set forth in this section. Documentation shall
include all of the following:
(A) A presentation of data to demonstrate reasons for the FQHC's
or RHC's request for a supplemental payment.
(B) Documentation showing the cost implications. The cost impact
shall be material and significant, two hundred thousand dollars
($200,000) or 1 percent of a facility's total costs, whichever is
less.
(4) A request shall be submitted for each affected year.
(5) Amounts granted for supplemental payment requests shall be
paid as lump-sum amounts for those years and not as revised PPS
rates, and shall be repaid by the FQHC or RHC to the extent that it
is not expended for the specified purposes.
(6) The department shall notify the provider of the department's
discretionary decision in writing.
(g) (1) An FQHC or RHC "visit" means a face-to-face encounter
between an FQHC or RHC patient and a physician, physician assistant,
nurse practitioner, certified nurse-midwife, clinical psychologist,
licensed clinical social worker, or a visiting nurse. For purposes of
this section, "physician" shall be interpreted in a manner
consistent with the federal Centers for Medicare and Medicaid
Services' Medicare Rural Health Clinic and Federally Qualified Health
Center Manual (Publication 27), or its successor, only to the extent
that it defines the professionals whose services are reimbursable on
a per-visit basis and not as to the types of services that these
professionals may render during these visits and shall include a
medical doctor, osteopath, podiatrist, dentist, optometrist, and
chiropractor. A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a comprehensive perinatal
practitioner, as defined in Section 51179.7 of Title 22 of the
California Code of Regulations, providing comprehensive perinatal
services, a four-hour day of attendance at an adult day health care
center, and any other provider identified in the state plan's
definition of an FQHC or RHC visit.
(2) (A) A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a dental hygienist, a dental
hygienist in alternative practice, or a marriage and family
therapist.
(B) Notwithstanding subdivision (e), an FQHC or RHC that currently
includes the cost of the services of a dental hygienist in
alternative practice, or a marriage and family therapist for the
purposes of establishing its FQHC or RHC rate shall apply for an
adjustment to its per-visit rate, and, after the rate adjustment has
been approved by the department, shall bill these services as a
separate visit. However, multiple encounters with dental
professionals or marriage and family therapists that take place on
the same day shall constitute a single visit. The department shall
develop the appropriate forms to determine which FQHC's or RHC's
rates shall be adjusted and to facilitate the calculation of the
adjusted rates. An FQHC's or RHC's application for, or the department'
s approval of, a rate adjustment pursuant to this subparagraph shall
not constitute a change in scope of service within the meaning of
subdivision (e). An FQHC or RHC that applies for an adjustment to its
rate pursuant to this subparagraph may continue to bill for all
other FQHC or RHC visits at its existing per-visit rate, subject to
reconciliation, until the rate adjustment for visits between an FQHC
or RHC patient and a dental hygienist, a dental hygienist in
alternative practice, or a marriage and family therapist has been
approved. Any approved increase or decrease in the provider's rate
shall be made within six months after the date of receipt of the
department's rate adjustment forms pursuant to this subparagraph and
shall be retroactive to the beginning of the fiscal year in which the
FQHC or RHC submits the request, but in no case shall the effective
date be earlier than January 1, 2008.
(C) An FQHC or RHC that does not provide dental hygienist, dental
hygienist in alternative practice, or marriage and family therapist
services, and later elects to add these services, shall process the
addition of these services as a change in scope of service pursuant
to subdivision (e).
(h) If FQHC or RHC services are partially reimbursed by a
third-party payer, such as a managed care entity (as defined in
Section 1396u-2(a)(1)(B) of Title 42 of the United States Code), the
Medicare program, or the Child Health and Disability Prevention
(CHDP) program, the department shall reimburse an FQHC or RHC for the
difference between its per-visit PPS rate and receipts from other
plans or programs on a contract-by-contract basis and not in the
aggregate, and may not include managed care financial incentive
payments that are required by federal law to be excluded from the
calculation.
(i) (1) An entity that first qualifies as an FQHC or RHC in the
year 2001 or later, a newly licensed facility at a new location added
to an existing FQHC or RHC, and any entity that is an existing FQHC
or RHC that is relocated to a new site shall each have its
reimbursement rate established in accordance with one of the
following methods, as selected by the FQHC or RHC:
(A) The rate may be calculated on a per-visit basis in an amount
that is equal to the average of the per-visit rates of three
comparable FQHCs or RHCs located in the same or adjacent area with a
similar caseload.
(B) In the absence of three comparable FQHCs or RHCs with a
similar caseload, the rate may be calculated on a per-visit basis in
an amount that is equal to the average of the per-visit rates of
three comparable FQHCs or RHCs located in the same or an adjacent
service area, or in a reasonably similar geographic area with respect
to relevant social, health care, and economic characteristics.
(C) At a new entity's one-time election, the department shall
establish a reimbursement rate, calculated on a per-visit basis, that
is equal to 100 percent of the projected allowable costs to the FQHC
or RHC of furnishing FQHC or RHC services during the first 12 months
of operation as an FQHC or RHC. After the first 12-month period, the
projected per-visit rate shall be increased by the Medicare Economic
Index (MEI) then in effect. The projected allowable costs for the
first 12 months shall be cost settled and the prospective payment
reimbursement rate shall be adjusted based on actual and allowable
cost per visit. The department shall finalize a new rate within one
year after the submission of the actual cost report from the first
full 12 months of operation and shall update the department provider
master file within 10 business days after finalizing the rate.
(D) The department may adopt any further and additional methods of
setting reimbursement rates for newly qualified FQHCs or RHCs as are
consistent with Section 1396a(bb)(4) of Title 42 of the United
States Code.
(2) (A) In order for an FQHC or RHC to establish the comparability
of its caseload, the department shall require that the FQHC or RHC
submit its most recent annual utilization report as submitted to the
Office of Statewide Health Planning and Development, unless the FQHC
or RHC was not required to file an annual utilization report. FQHCs
or RHCs that have experienced changes in their services or caseload
subsequent to the filing of the annual utilization report may submit
to the department a completed report in the format applicable to the
prior calendar year. FQHCs or RHCs that have not previously submitted
an annual utilization report shall submit to the department a
completed report in the format applicable to the prior calendar year.
The FQHC or RHC shall not be required to submit the annual
utilization report for the comparable FQHCs or RHCs to the
department, but shall be required to identify the comparable FQHCs or
RHCs. This paragraph shall apply only to a facility that selects the
comparability approach described in subparagraph (A) or (B) of
paragraph (1).
(B) The department shall conduct an initial review of the three
FQHCs or RHCs for the purpose of determining comparability within 30
days after submission by the new entity. If the department determines
one or more of the submitted centers or clinics do not meet the
comparability threshold, the department shall notify the new entity
no later than the 31st day after submission.
(C) The notification shall state the reason or reasons for the
finding of noncomparability and shall request a supplemental
submission from the new entity. The request shall clearly state
whether the new entity shall submit data from one, two, or three
FQHCs or RHCs to meet the comparability threshold. Once the new
entity submits its supplemental information, the initial review
process described in subparagraph (B) shall apply.
(D) Within one year after receiving a submission determined by the
department to be comparable, the department shall finalize the new
entity's rate and shall update the provider master file within 10
business days.
(3) The rate for any newly qualified entity set forth under this
subdivision shall be effective retroactively to the later of the date
that the entity was first qualified by the applicable federal agency
as an FQHC or RHC, the date a new facility at a new location was
added to an existing FQHC or RHC, or the date on which an existing
FQHC or RHC was relocated to a new site. The FQHC or RHC shall be
permitted to continue billing for Medi-Cal covered benefits on a
fee-for-service basis under its existing provider number, until it is
informed of its FQHC or RHC enrollment approval, and the department
shall reconcile the difference between the fee-for-service payments
and the FQHC's or RHC's prospective payment rate at that time.
(j) Visits occurring at an intermittent clinic site, as defined in
subdivision (h) of Section 1206 of the Health and Safety Code, of an
existing FQHC or RHC, or in a mobile unit as defined by paragraph
(2) of subdivision (b) of Section 1765.105 of the Health and Safety
Code, shall be billed by and reimbursed at the same rate as the FQHC
or RHC establishing the intermittent clinic site or the mobile unit,
subject to the right of the FQHC or RHC to request a scope-of-service
adjustment to the rate.
(k) An FQHC or RHC may elect to have pharmacy or dental services
reimbursed on a fee-for-service basis, utilizing the current fee
schedules established for those services. These costs shall be
adjusted out of the FQHC's or RHC's clinic base rate as
scope-of-service changes. An FQHC or RHC that reverses its election
under this subdivision shall revert to its prior rate, subject to an
increase to account for all Medicare Economic Index increases
occurring during the intervening time period, and subject to any
increase or decrease associated with applicable scope-of-service
adjustments as provided in subdivision (e).
( l ) FQHCs and RHCs may appeal a grievance or
complaint concerning ratesetting, scope-of-service changes, and
settlement of cost report audits, in the manner prescribed by Section
14171. The rights and remedies provided under this subdivision are
cumulative to the rights and remedies available under all other
provisions of law of this state.
(m) The department shall, no later than March 30, 2008, promptly
seek all necessary federal approvals in order to implement this
section, including any amendments to the state plan. To the extent
that any element or requirement of this section is not approved, the
department shall submit a request to the federal Centers for Medicare
and Medicaid Services for any waivers that would be necessary to
implement this section.
(n) The department shall implement this section only to the extent
that federal financial participation is obtained.
(o) The department shall correct erroneous payments at least
quarterly to reprocess past claims and ensure all claims are
reimbursed at the finalized new rate determined pursuant to either
subdivision (e) or (i).
SEC. 2. Section 1.5 of this bill incorporates amendments to
Section 14132.100 of the Welfare and Institutions Code proposed by
both this bill and Senate Bill 610. It shall only become operative if
(1) both bills are enacted and become effective on or before January
1, 2016, (2) each bill amends Section 14132.100 of the Welfare and
Institutions Code, and (3) this bill is enacted after Senate Bill
610, in which case Section 1 of this bill shall not become operative.
