Chapter 5160-16 Rural Health Services

5160-16-01 Rural health clinics (RHCs): definitions and eligibility.

The following terms as used in Chapter 5101:3-16 of the Administrative Code are defined as follows:

(A) An "alternative payment clinic" is an outpatient health facility (OHF), federally qualified health center (FQHC), or rural health clinic (RHC). Medicaid providers may be enrolled as only one type of alternative payment clinic.

(B) "Billable services" for RHCs are services identified in rule 5101:3-16-02 of the Administrative Code and provided in accordance with Chapter 5101:3-16 of the Administrative Code.

(C) A "federally qualified health center (FQHC)" is defined in accordance with rule 5101:3-28-01 of the Administrative Code.

(D) An "outpatient health facility (OHF)" is defined in accordance with rule 5101:3-29-01 of the Administrative Code.

(E) A "rural health clinic (RHC)" is a clinic certified by the Ohio department of health (ODH) as meeting the conditions of certification for rural health clinics under Title XVIII of the Social Security Act (medicare).

(1) Requirements for RHCs are listed in 42 C.F.R. part 491, effective October 1, 2005.

(2) The centers for medicare and medicaid services (CMS) deems that RHCs approved for medicare participation meet the standards for certification under medicaid.

(F) An "encounter" is defined as a face-to-face contact between a patient and provider(s) of covered services, except for transportation services. Encounters involving more than one health professional for the same unit of service, and multiple interactions with the same health professional, that take place on the same day and at a single location constitute a single encounter, except when the patient, after the first interaction, suffers illness or injury requiring additional diagnosis or treatment. Encounters shall be documented in the patient health record.

(G) "Nurse practitioner" means a an advanced practice nurse, as defined in accordance with rule 5101:3-8-20 of the Administrative Code.

(H) "Physician assistant" is defined in accordance with rule 5101:3-4-03 of the Administrative Code.

(I) "Nurse-midwife" is an advanced practice nurse, as defined in rule 5101:3-8-20 of the Administrative Code.

(J) A "clinical social worker" means an individual who:

(1) Possesses a master's or doctoral degree in social work;

(2) After obtaining such degree has performed at least two years of supervised clinical social work; and

(3) Is licensed to practice as a "licensed independent social worker" in accordance with division (B) of section 4757.27 of the Revised Code or as a "licensed social worker" in accordance with division (A) of section 4757.28 of the Revised Code and who is supervised by a licensed independent social worker, psychologist or physician.

(K) A "clinical psychologist" means an individual who:

(1) Holds a doctoral degree in psychology from a program in clinical psychology of an educational institution that is accredited by an organization recognized by the "Council on Post-Secondary Accreditation";

(2) Is licensed in accordance with division (B) of section 4732.10 of the Revised Code; and

(3) Possesses two years of supervised clinical experience, at least one of which is postdegree.

(L) "Physician supervision" is defined in accordance with rule 5101:3-4-02 of the Administrative Code. For the purposes of Chapter 5101:3-16 of the Administrative Code, physician supervision also includes:

(1) Medical direction for the RHC's health care activities and consultation for, and medical supervision of, the health care staff;

(2) In conjunction with the physician's assistant and/or nurse practitioner member(s), developing, executing, and periodically reviewing the RHC's written policies and the services provided to federal program patients;

(3) Periodic reviews of the RHC's patient records, provision of medical orders, and provision of medical care services to patients of the clinic; and

(4) Attendance, for sufficient periods of time, at least once in every two-week period (except in extraordinary circumstances), to provide the medical direction, medical care services, consultation and supervision described in paragraph (J)(1)(M)(1) of this rule, and availability, through direct telecommunication for consultation, for assistance with medical emergencies, or patient referral. The extraordinary circumstances are documented in the records of the RHC.

Replaces: 5101:3-16-04

Effective: 07/01/2006
R.C. 119.032 review dates: 03/30/2006 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/1/80, 6/1/91, 7/1/01

5160-16-02 Rural health clinics (RHCs): covered services.

RHCs are required to provide a core set of services. The scope of the services furnished by RHCs is comparable to services provided in a physician's office. Services furnished by RHCs may be provided by physicians and mid-level practitioners, including physician assistants, nurse practitioners, and certified nurse-midwives. Services also include outpatient mental health services furnished by clinical psychologists and clinical social workers.

(A) Covered RHC services are:

(1) Services furnished by a physician, physician assistant, nurse practitioner, or nurse-midwife:

(a) In accordance with Chapter 5101:3-4 of the Administrative Code; and

(b) Within the scope of practice of his or her profession under state law.

(2) Services furnished by a clinical psychologist and:

(a) Defined in accordance with paragraph (B)(8) of rule 5101:3-28-03 of the Administrative Code; and

(b) In accordance with the limitations specified in rule 5101:3-8-05 of the Administrative Code.

(3) Services by a clinical social worker for the diagnosis and treatment of mental illness and:

(a) Billable under physician supervision in accordance with rule 5101:3-4-29 of the Administrative Code;

(b) Defined in accordance with paragraph (B)(8) of rule 5101:3-28-03 of the Administrative Code; and

(c) In accordance with the limitations specified in rule 5101:3-16-03 of the Administrative Code.

(4) Services and supplies furnished as incident to professional services and services furnished by a physician and services and supplies furnished as incident to services provided by a physician assistant, nurse practitioner, nurse-midwife, clinical psychologist, or clinical social worker, as would otherwise be covered if furnished as incident to a physician service(s).

(5) Visiting nurse services if:

(a) The RHC is located in an area in which the United States secretary of health and human services has determined that there is a shortage of home health agencies;

(b) The services are furnished by a registered nurse or a licensed practical nurse employed by, or otherwise compensated for the services by, the RHC;

(c) The services are furnished to a homebound individual; and

(d) The services are furnished under a written plan of treatment that is established and reviewed at least every sixty days by a supervising physician of the RHC or that is established by a physician, physician assistant or nurse practitioner and reviewed at least every sixty days by a supervising physician of the RHC and signed by the physician, physician assistant, nurse practitioner, or supervising physician

(B) The following services are not billable under a provider's RHC provider number. These services should be billed by an RHC under a different medicaid provider number as a fee-for-service ambulatory clinic provider:

(1) Inpatient hospital surgery;

(2) Inpatient hospital visits or consultations;

(3) Medicare crossover claims that are not paid through the automatic medicare crossover process in accordance with rule 5101:3-1-05 of the Administrative Code;

(4) Disability assistance program claims;

(5) Take home drugs shall be billed through the pharmacy program as described in Chapter 5101:3-9 of the Administrative Code; and

(6) Durable medical equipment (DME) for take-home use shall be billed through the DME program in accordance with rule 5101:3-10 of the Administrative Code

(C) For dates of service on and after January 1, 2006, the Ohio department of job and family services (ODJFS) shall institute a co-payment program under medicaid in accordance with rule 5101:3-1-09 of the Administrative Code. This co-payment program shall also apply to services rendered by an RHC. Specific information regarding implementation of co-payments in managed care settings are located in Chapter 5101:3-26 of the Administrative Code

(D) Provisions regarding outpatient hospital services identified in rule 5101:3-2-03 of the Administrative Code also apply to RHCs.

Replaces: 5101:3-16-02

Effective: 07/01/2006
R.C. 119.032 review dates: 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/1/80, 6/1/91, 7/1/01

5160-16-03 Rural health clinics (RHCs): limitations and noncovered services.

RHC services are reimbursable only if:

(A) Furnished by a physician as defined in accordance with rule 5101:3-4-01 of the Administrative Code.;

(B) Furnished by a nurse practitioner, or nurse -midwife, defined in accordance with rule 5101:3-8-21 of the Administrative Code, who is:

(1) Under the medical supervision of a physician as defined in paragraph (L) of rule 5101:3-16-01 of the Administrative Code;

(2) Performing such services in accordance with Chapter 4723. of the Revised Code; and

(3) Employed by, or receives compensation from, the RHC.

(C) Furnished by a physician assistant, defined in accordance with rule 5101:3-4-03 of the Administrative Code, who is:

(1) Under the medical supervision of a physician as defined in paragraph (L) of rule 5101:3-16-01 of the Administrative Code;

(2) Performing such services in accordance with Chapter 4730. of the Revised Code; and,

(3) Employed by, or receives compensation from, the RHC.

(D) Furnished by a clinical psychologist, in accordance with rule 5101:3-8-05 of the Administrative Code.

(E) Furnished by a clinical social worker, in accordance with rule 5101:3-4-29 of the Administrative Code.

(F) Relative to visiting nurse services, such services are covered if: provided in accordance with rule 5101:3-16-02 of the Administrative Code.

(G) Coverage limitations in RHCs.

(1) Coverage limitations set forth in Chapter 5101:3-4 of the Administrative Code apply to RHC services provided by physicians and physician assistants.

(2) Coverage limitations set forth in rule 5101:3-8-23 of the Administrative Code also apply to advanced practice nurse services provided under the auspices of an RHC.

(3) Coverage limitations set forth in rules 5101:3-8-05 and 5101:3-4-29 of the Administrative Code also apply to mental health services provided under the auspices of an RHC.

(H) RHC billable services.

(1) RHC services shall be billed on an encounter basis, in accordance with rule 5101:3-4-02 of the Administrative Code.

(2) All billable encounters shall be documented in the patient health record in accordance with rule 5101:3-1-27 of the Administrative Code.

(3) For consumers in the medicaid managed care program, claims submission requirements, including prior authorization requests for RHC services as defined in Chapter 5101:3-16 of the Administrative Code, are specified in rules 5101:3-26-03.1 and 5101:3-26-05.1 of the Administrative Code.

Effective: 07/01/2006
R.C. 119.032 review dates: 03/30/2006 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/1/80, 8/1/01

5160-16-05 Rural health clinics -(RHCs): supplemental payments.

(A) Definitions:

(1) "MCP" means a managed care plan as defined in rule 5101:3-26-01 of the Administrative Code that reimburses a rural health clinic(RHC) for services provided by the RHC to a medicaid recipient enrolled in the MCP.

(2) "Encounter" is defined in accordance with rule 5101:3-16-01 of the Administrative Code.

(3) "Enrollee," otherwise known as a member, means each eligible individual enrolled in an MCP as specified in rule 5101:3-26-01 of the Administrative Code.

(B) Effective for services furnished on or after January 1, 2001, RHCs that have received payment from an MCP for RHC services identified in rule 5101:3-16-02 of the Administrative Code are eligible to receive a supplemental payment from the department if the amount the RHC was paid by an MCP for services provided to an MCP enrollee is less than the amount the RHC would have received under the prospective payment system(PPS) reimbursement method described in rule 5101:3-16-06 of the Administrative Code.

(C) To receive the supplemental payment for an encounter provided to an MCP enrollee, an RHC must submit a claim to the department following the Ohio medicaid provider billing instructions utilized by RHCs for fee-for-service medicaid consumers with third party insurance.

(1) These billing instructions require an RHC to report the following on the claim:

(a) The encounter code and the appropriate modifier to signify the type of encounter provided by the RHC.

(i) RHCs that choose to submit a paper claim must submit the standard professional claim form.

(ii) RHCs that choose to submit a claim via an electronic transaction shall submit the transaction in an electronic format recognized by the department in accordance with the department's billing instructions.

(b) A detailed CPT code listing reflecting all services provided during the encounter.

(2) RHCs seeking supplemental payments must also report the following information on the claim:

(a) The third party indicator for the medicaid supplemental payment;

(b) The medicaid identification number of the MCP that paid the RHC in the referring physician field; and

(c) The sum of the dollar amount the RHC was paid by any MCP for the service(s) provided to the medicaid recipient listed on the claim, minus any incentive payments received from an MCP and any amount received by the RHC from any other third party insurance.

(3) The data elements submitted for a supplemental payment claim are dependent on whether the claim is a paper claim or an electronic transaction.

(a) RHCs that choose to submit a paper claim shall submit the data elements outlined in paragraphs (C)(1) and (C)(2) of this rule; and

(b) RHCs that choose to submit a claim via an electronic transaction shall use the "837" transaction and report the data elements unique for supplemental claims, including:

(i) The name of the MCP provider under the "other payer name" field;

(ii) The "identification code," as assigned by the Ohio department of job and family services (ODJFS), of the MCP payer that initially paid for the services; and

(iii) The sum of the dollar amount the MCP paid the RHC for services without regard to the effects of any financial incentive payments (positive or negative) received from the MCP plus any amount received from any other third party insurance, in "monetary amount" under the "other payer" field.

(D) Calculation of supplemental payments:

(1) Using the methodology described in paragraph (C) of this rule, the department will pay the RHC no less frequently than every four months.

(2) For dates of service on and after January 1, 2001, upon receipt of the claim the department will pay any difference between the amount paid by the MCP to the RHC and the amount due the RHC based on its PPS rate approved by the department for the specific claim submitted.

The department's supplemental payment obligation will be determined using the baseline payment that the RHC would have received under PPS reimbursement as described in rule 5101:3-16-06 of the Administrative Code, without regard to the effects of any financial incentives(positive or negative) received from the MCP that are linked to utilization outcomes or other reductions in patient costs.

(E) If a claim is not submitted by an RHC to the department within the standard time frames required for claims submission in accordance with rule 5101:3-1-19.3 of the Administrative Code, no supplemental payment(s) will be made by the department to the RHC.

Effective: 07/01/2006
R.C. 119.032 review dates: 03/30/2006 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 8/6/01

5160-16-06 Rural health clinics (RHCs): 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 new medicaid prospective payment system (PPS) for RHCs. This rule addresses how the department complies with BIPA requirements.

(B) Definitions:

(1) "Base rate" is the initial PPS rate assigned to an RHC.

(2) For the purposes of Chapter 5101:3-16 of the Administrative Code, "change in scope of service" is defined in accordance with paragraph (A)(1)(b) of rule 5101:3-28-09 of the Administrative Code. For the purposes of Chapter 5101:3-16 of the Administrative Code, references to federally qualified health centers in paragraph (B) of rule 5101:3-28-09 of the Administrative Code also apply to RHCs.

(C) Establishment of PPS rates for RHCs:

(1) For RHCs in operation during their fiscal year 1999, the base rate is the average of that RHC's medicare reimbursement rate per visit for its fiscal years 1999 and 2000.

(2) For RHCs beginning operation after their fiscal year 2000, the base rate is the same as the rate(s) established for other RHCs in the nearest adjacent area that are similar in size, caseload, and scope of services. If there is not an RHC in an adjacent area that is similar in size, caseload, and scope of services, the state-wide sixtieth percentile rate will be assigned to the new RHC as the start-up PPS rate.

(3) On October 1 of each subsequent year of operation, all PPS rates in effect for RHCs on September 30th will be increased by the percentage increase in the latest available medicare economic index (MEI).

(D) An RHC may request a PPS rate review upon incurring a change in scope of services. Provisions regarding review of change of scope of service for federally qualified health centers (FQHCs) in paragraph (C) of rule 5101:3-28-09alsoapply to RHCs, with the exception that RHCs shall utilize the independent rural health clinic and freestanding federally qualified health center cost report form(CMS-222-92), dated 1/2005, for the purpose of filing cost reports, rather that the JFS 03421, as described in paragraph (C)(7)(e) of rule 5101:3-28-09 of the Administrative Code.

Effective: 07/01/2006
R.C. 119.032 review dates: 03/30/2006 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 10/15/01