5101:3-28-08 Federally qualified health centers (FQHCs): general provisions of the prospective payment system (PPS).

(A) Section 702 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 requires states to establish a medicaid prospective payment system (PPS) for FQHCs. This rule addresses how the department complies with BIPA requirements.

(B) Cost report filing provisions are specified in rule 5101:3-28-10 of the Administrative Code.

(C) On October first of each year thereafter:

(1) All PPS rates in effect on September thirtieth will be inflated by the percentage increase in the latest available medicare economic index (MEI);

(2) The department will calculate the sixtieth percentile for urban and for rural FQHCs. The most recently calculated sixtieth percentile will be used for any rate assignments occurring from October first and through September thirtieth due to changes in scope of service as described in paragraph (B) of rule 5101:3-28-09 of the Administrative Code or for the start-up rate for newlyqualified FQHCs; and

(3) The transportation payment value in effect on September thirtieth will be inflated by the percentage increase in the latest available MEI for primary care services. The most recently calculated transportation value will be used for any rate assignments occurring from October first through September thirtieth.

(D) Newly qualified FQHCs.

(1) Newly qualified FQHCs as specified in rule 5101:3-28-01 of the Administrative Code will have their base PPS rate(s) set based on the rates established for other FQHCs in the nearest adjacent area that are similar in size, caseload, and scope of services. If there is no FQHC in the nearest adjacent area that is similar in size, caseload, and scope of services, the state-wide urban or state-wide rural sixtieth percentile rate(s) in accordance with paragraph (C)(2) of this rule will be assigned to the newly qualified FQHC as the start-up PPS rate(s).

(2) After the start-up rate is set, the following procedures will occur:

(a) The newly- qualified FQHC will file a cost report in accordance with paragraph (B)(1) of rule 5101:3-28-10 of the Administrative Code;

(b) Base rate(s) for the newly qualified FQHCs will be set based on their newly- qualified FQHC's costs reported on the cost report and based on the principles described in paragraphs (B)(3) to (B)(7)(e) of rule 5101:3-28-09 of the Administrative Code;

(c) The start-up rate(s) will be adjusted. The new PPS base rate will be the rate established using the principles described in paragraphs (B)(3) to (B)(7)(e) of rule 5101:3-28-09 of the Administrative Code adjusted by any MEI increases that may have occurred since the filing of the FQHC's cost report.

(d) The rate will be effective within sixty days of receipt of a complete and accurate cost report.

(3) The wage index for urban areas or the wage index for rural areas used to establish the rate(s) for newly- qualified FQHCs shall be the most recent index applicable to the newly- qualified FQHC's location published in the Federal Register for the year in which the new FQHC is eligible to become an Ohio medicaid provider.

(4) In future years, the PPS rate(s) will be adjusted by the MEI in accordance with paragraph (C) of this rule.

(E) Each FQHC service site must obtain its own PPS rate for each type of service provided. An FQHC service site may not use a PPS rate of another service site to bill medicaid.

Effective: 07/01/2006
R.C. 119.032 review dates: 03/09/2006 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 10/25/01