5101:3-28-08.1 Federally qualified health center (FQHC): alternate payment method (APM).

This rule describes an alternate payment method (APM) that may be selected, with approval from the department, by an FQHC operated by a state or local governmental entity (a "government-operated FQHC"). This APM applies only to FQHC services included in cost reports submitted on or after July 1, 2011.

(A) Within one hundred twenty days after the close of a fiscal year, the government-operated FQHC must use a "Federally Qualified Health Center / Outpatient Health Facility Cost Report," form JFS 03421 (rev. 07/2001), to compile and submit an initial cost report of all services delivered during that fiscal year. A government-operated FQHC that has more than one service site must submit separate cost reports for the individual sites.

(B) When it submits an initial cost report, the government-operated FQHC must certify to the department that its costs were an expenditure of public funds not derived from a federal funding source and not otherwise used as a state or local match for federal funds.

(C) After it receives a complete and accurate initial cost report and certification, the department will perform a desk audit of the cost report and determine the amount for which the government-operated FQHC is eligible to receive federal matching funds.

(1) No additional limitation, test of reasonableness, or ceiling described in rule 5101:3-28-09 of the Administrative Code is applied to the initial cost report. The resulting figures represent the total actual allowable costs during the fiscal year.

(2) From these figures, the "average cost per visit" for each FQHC service offered at the site is obtained by dividing the total allowable cost for the service by the total number of visits.

(3) For each FQHC service, the "total allowable medicaid cost" for the fiscal year is the product of the average cost per visit and the number of visits made by medicaid-eligible individuals.

(4) The "total medicaid reimbursement" for an FQHC service during a fiscal year is the sum of reimbursement amounts received by an FQHC under the prospective payment system (PPS), payments made by medicaid managed care plans, and managed care supplemental ("wraparound") payments made by the department.

(5) If the total allowable medicaid cost for an FQHC service exceeds the total medicaid reimbursement, then the department will calculate the federal share of the difference (the "medicaid gap") by applying the appropriate federal match percentage. The department will then remit the federal share for each FQHC service to the government-operated FQHC. This payment is a supplement to, not a substitute for, the total medicaid reimbursement defined in paragraph (C)(4) of this rule.

(D) Within five hundred days after the close of a fiscal year, the government-operated FQHC must use form JFS 03421 to submit a fully audited cost report of all services delivered during that fiscal year. A government-operated FQHC that has more than one service site must submit separate cost reports for the individual sites. From the audited cost report, the department will follow the procedure described in paragraph (C) of this rule to calculate the federal share of the medicaid gap for each FQHC service offered by the government-operated FQHC. If the federal share of the medicaid gap based on the initial cost report is greater than the federal share of the medicaid gap based on the fully audited cost report, then the government-operated FQHC must remit the difference to the department within thirty days; if it is less, then the department must remit the difference to the government-operated FQHC. For payment purposes, the federal share amounts for the various FQHC services offered at a single site may be aggregated.

Effective: 10/01/2012
R.C. 119.032 review dates: 10/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021