NOTICES
DEPARTMENT OF HUMAN SERVICES
Federally Qualified Health Center and Rural Health Clinic Alternative Payment Methodologies
[46 Pa.B. 7485]
[Saturday, November 26, 2016]This notice announces implementation of alternative payment methodologies (APM) for delivery services provided in the Federally Qualified Health Center (FQHC) setting, delivery services provided by FQHC personnel in the acute care general hospital (hospital) inpatient setting, and the payment by managed care organizations (MCO) to FQHCs and Rural Health Clinics (RHC) of rates that are not less than the Department of Human Services (Department) Fee-for-Service (FFS) Prospective Payment System (PPS) rate for beneficiary encounters.
Background
Section 1902(bb)(1) of the Social Security Act (42 U.S.C.A. § 1396a(bb)(1) provides for payment to FQHCs and RHCs using a PPS methodology. For services provided to managed care beneficiaries, states pay supplemental payments equal to the amount the FQHC or RHC 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 Secuity Act.
The Department received requests from stakeholders for the Medical Assistance (MA) Program to pay FQHCs for delivery services rendered by FQHC personnel in the inpatient setting and delivery services rendered in the FQHC setting.
In addition, on January 1, 2016, the physical health and behavioral health HealthChoices MCOs began paying FQHCs and RHCs fees that are no less than the PPS rate. However, as a result of the State Health Official letter No. 16-006, this is now considered an APM.
APM for FQHC Personnel Performing Delivery Services in a Hospital Inpatient Setting
Effective with dates of services on and after December 1, 2016, the Department will implement an APM to pay the FQHC a practitioner's fee for a delivery performed in an inpatient hospital setting from the MA Program Fee Schedule as follows:
Procedure
CodeDescription Provider
TypeProvider
SpecialtyPlace of
ServicePricing
ModifierMA Fee MA units Limits 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 08 080 21 $1,200 per procedure One per beneficiary per pregnancy 59514 Cesarean delivery only 08 080 21 $1,200 per procedure One per beneficiary per pregnancy 80 $240 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 08 080 21 $1,500 per procedure One per beneficiary per pregnancy 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 08 080 21 $1,500 per procedure One per beneficiary per pregnancy 80 $300 APM for Delivery Services Performed in the FQHC Setting
Effective with dates of service on and after December 1, 2016, the Department will implement an APM to continue to pay the FQHC's PPS rate for all beneficiary prenatal visits, as well as a fee for delivery services that includes both the practitioner and facility payments.
The Department developed the FQHC delivery rate by utilizing historical cost data supplied by birth centers, an alternative provider of outpatient delivery services, enrolled in the MA Program and then proportionally adjusting the cost for pregnancy by trimester. The resulting costs associated with the third trimester obstetrical services were then reduced by the minimum five office visits expected in that trimester, which FQHCs can bill as an encounter. The Department determined the cost of the delivery for the practitioner and the facility to be $1,129 per encounter.
Procedure
CodeDescription Provider
TypeProvider
SpecialtyPlace of
ServicePricing
ModifierMA Fee MA units Limits T1015 Clinic visit/ encounter, all-inclusive 08 080 50 U4 $1,129 per encounter One per beneficiary per pregnancy APM for MCOs Paying the PPS Rate to FQHCs/RHCs
As previously set forth, the MCOs shall continue to pay all FQHCs and RHCs rates that are not less than the FFS PPS rates as determined by the Department. The Department is submitting a State Plan Amendment to identify this as an APM.
Fiscal Impact
These changes result in a minimal fiscal impact to the MA Program.
Public Comment
Interested persons are invited to submit written comments regarding these changes 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).
THEODORE DALLAS,
SecretaryFiscal Note: 14-NOT-1081. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 16-2051. Filed for public inspection November 23, 2016, 9:00 a.m.]
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