NOTICES
DEPARTMENT OF
HUMAN SERVICES
Federally Qualified Health Center Alternative Payment Methodology
[49 Pa.B. 1615]
[Saturday, March 30, 2019]This notice announces implementation of an alternative payment methodology (APM) for services provided by qualified public Federally Qualified Health Centers (FQHC) and FQHC look-alikes operated by a city of the first class, effective for a 3-year period beginning April 1, 2019, subject to the approval of the Centers for Medicare & Medicaid Services (CMS). The APM will provide additional funds to qualified FQHCs that provide a high volume of services to Medical Assistance (MA) beneficiaries and individuals with no insurance to allow the FQHCs to develop and offer additional services.
Background
Section 1902(bb)(1) of the Social Security Act (42 U.S.C.A. § 1396a(bb)(1)) provides for payment to FQHCs using a Prospective Payment System (PPS) methodology. For services provided to beneficiaries receiving services in a managed care delivery system, states must make supplemental payments equal to the amount the FQHC would have been paid under the PPS. See section 1902(bb)(5) of the Social Security Act. States can also pay providers using an APM. See section 1902(bb)(6) of the Social Security Act.
The MA Program uses a PPS methodology to pay for most services provided by FQHCs but does have two approved APMs. One APM requires physical health and behavioral health HealthChoices managed care organizations to pay FQHCs no less than Department of Human Services (Department) determined PPS rates, and the other pays FQHCs a practitioner's fee for obstetrical deliveries performed in an inpatient hospital setting. See 46 Pa.B. 7485 (November 26, 2016) and 47 Pa.B. 3049 (May 27, 2017).
APM for FQHCs Operated by a City of the First Class
To qualify for this additional APM, the FQHC must be located in and operated by a city of the first class and agree to the APM in writing.
For dates of service from April 1, 2019, through March 31, 2022, subject to the approval of CMS, the Department will pay qualified FQHCs an additional payment amount that, when combined with other payments from all sources including, but not limited to, Health Resources and Services Administration grants and co-pays, does not exceed 100% of the allowable costs incurred in the provision of covered MA and uninsured services. The Department will calculate and pay the additional amount on a quarterly basis by applying a rate determined by the Department based on the FQHCs allowable costs as identified in the FQHCs most recently reviewed and accepted MA Cost Report, as trended to the payment year, to the number of actual services provided to MA and eligible uninsured individuals during the quarter in which the services were provided. Individuals lacking documentation for legal residency and individuals not eligible for Federally-funded MA for 5 years beginning with the date the individual obtained qualified noncitizen status, including lawfully admitted permanent residents and refugees, are not eligible as uninsured individuals for the purpose of this payment. See 8 U.S.C.A. §§ 1611 and 1612; 42 U.S.C.A. § 1396b(v).
Fiscal Impact
The estimated annual fiscal impact, as a result of the funding allocation for these payments, is $24.418 million.
Public Comment
Interested persons are invited to submit written comments regarding this APM to the Department of Human Services, Office of Medical Assistance Programs, c/o Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 30 days will be reviewed and considered.
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
TERESA D. MILLER,
SecretaryFiscal Note: 14-NOT-1320. (1) General Fund; (2) Implementing Year 2018-19 is $0; (3) 1st Succeeding Year 2019-20 is $7,500,000; 2nd Succeeding Year 2020-21 through 3rd Succeeding Year 2021-22 are $10,001,000; 4th Succeeding Year 2022-23 is $2,501,000; 5th Succeeding Year 2023-24 is $0; (4) 2017-18 Program—$477,690,000; 2016-17 Program—$450,970,000; 2015-16 Program—$392,918,000; (7) MA—Fee-for-Service; (8) recommends adoption. There is no fiscal impact in the current fiscal year. Funds should be included in the budget to cover increases.
[Pa.B. Doc. No. 19-467. Filed for public inspection March 29, 2019, 9:00 a.m.]
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