Chapter 5160-28 | Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) Services

Rule 5160-28-01 | Federally qualified health center (FQHC) and rural health clinic (RHC) services: definitions and explanations.

• Effective: July 1, 2022
• Promulgated Under: 119.03

(A) "Change in scope of service" is an alteration in aspects of a prospective payment system (PPS) service such as the procedures or items that are furnished, the frequency with which they are furnished, and the type of personnel who furnish them.

(1) A change in scope of service is characterized by such factors as are specified in the following non-exhaustive list:

(a) The addition or discontinuation of a PPS service;

(b) The addition or discontinuation of a procedure or class of procedures within a PPS service that involves the skills and training of a higher-level practitioner, such as the expansion of PPS medical service to include obstetrical-gynecological care provided by a physician or advanced practice registered nurse or the provision of a full range of dental procedures performed by a licensed dentist where previously only the services of a dental hygienist had been available; or

(c) A change in the distribution of procedures within a PPS service that materially affects the allocation of resources to that PPS service, such as a change in a medical service "case mix" from eighty per cent family practice and twenty per cent obstetrical-gynecological care to forty per cent family practice and sixty per cent obstetrical-gynecological care.

(2) The following factors do not constitute a change in scope of service:

(a) Wage increases;

(b) Changes in negotiated union contracts;

(c) Renovations or other capital expenditures;

(d) An increase in the number of lower-level staff members, such as a nurse practitioner at a site that employs a family physician, a dental hygienist at a site that employs a dentist, or a physical therapy assistant at a site that employs a physical therapist;

(e) An increase in the number of social service staff members;

(f) An increase in office space, such as the addition of square footage at an FQHC or RHC, a satellite office, a school location, or a mobile unit;

(g) An increase in equipment or supplies;

(h) An increase in patient volume;

(i) An increase in office hours;

(j) The addition of an adjunctive service such as a disease management program; or

(k) Provision of a PPS service by an FQHC or RHC practitioner at a related off-site location.

(B) "Cost report" is a report of FQHC or RHC costs together with all schedules, attachments, and supporting documentation, in accordance with the instructions specified for the form.

(1) For purposes of establishing FQHC per-visit payment amounts, the Ohio department of medicaid (ODM) uses form ODM 03421, "Federally Qualified Health Center Cost Report" (rev. 7/2022).

(2) For purposes of establishing RHC per-visit payment amounts, ODM uses the appropriate medicare form, either CMS-222-17, "Independent Rural Health Clinic Cost Report" (rev. 5/2018) or CMS 2552-10, "Hospital and Hospital Health Care Complex Cost Report Certification and Settlement Summary" (rev. 4/2020).

(C) "Federally qualified health center (FQHC)" is an entity that meets the definition of FQHC set forth in 42 U.S.C. 1395x(aa)(4) (October 1, 2021).

(1) "FQHC look-alike" is an FQHC that does not receive Public Health Service Act (PHSA) grant funding.

(2) "Government-operated FQHC" is an FQHC operated by a state, county, or local government agency.

(D) "Managed care entity (MCE)" has the same meaning as in Chapter 5160-26 of the Administrative Code.

(E) "Medicaid wraparound payment" is an amount that is paid by ODM to augment the payment made by an MCE to an FQHC or RHC. It equals any positive difference obtained when the MCE payment is subtracted from the per-visit payment amount (PVPA) for the visit.

(1) For purposes of determining timely filing in accordance with rule 5160-1-19 of the Administrative Code, an MCE is treated as a third-party payer.

(2) An FQHC or RHC may submit a claim to ODM for medicaid wraparound payment before the later of the following dates:

(a) One hundred eighty days after the date on which the MCE pays the original claim; or

(b) Three hundred sixty-five days after the date of service.

(3) ODM will pay a valid claim for medicaid wraparound payment within four months after submission.

(F) "Non-PPS service" is a service rendered at an FQHC or RHC for which payment is generally made in accordance with rules in agency 5160 outside of Chapter 5160-28 of the Administrative Code.

(G) "PPS" means prospective payment system.

(H) "Per-visit payment amount (PVPA)" is the amount of medicaid payment established for a visit for which payment is made under the PPS method described in rule 5160-28-05 of the Administrative Code.

(I) "PPS payment" is payment that is made under the PPS method described in rule 5160-28-05 of the Administrative Code.

(J) "PPS service" is a service that is rendered during a visit for which PPS payment is made.

(K) "Related off-site location" is a place other than an FQHC or RHC site at which a service is performed, such as a school, a satellite office, a mobile unit, a long-term care facility, an outpatient hospital setting used by an FQHC or RHC for providing services to patients, or a practice location operated by an FQHC- or RHC-contracted practitioner. For reporting purposes, a service rendered at a related off-site location is attributed to the particular FQHC or RHC site whose personnel provided the service.

(L) "Related organization" is an organization that is related to an FQHC or RHC by common ownership or control.

(M) "Rural health clinic (RHC)" is an entity that meets the definition of RHC set forth in 42 U.S.C. 1395x(aa)(2) (October 1, 2021).

(N) "Services and supplies furnished incident to" other services has the same meaning as in chapter 13 of "Centers for Medicare and Medicaid Services (CMS) Publication 100-02, Medicare Benefit Policy Manual" (December 20, 2019), which is available at http://www.cms.gov.

(O) "Site," as used in this chapter of the Administrative Code, is a separate and distinct location operated by an FQHC or RHC at which healthcare services are rendered. An FQHC or RHC may have several sites.

(P) "Visit."

(1) For PPS services other than transportation, a visit is one face-to-face (person-to-person) encounter between a patient and a provider; for medicaid payment purposes, a covered service rendered through telehealth by an FQHC or RHC practitioner is a face-to-face encounter. For transportation services, a visit is a one-way trip provided to or from a site where a covered service is rendered on the same date.

(a) Multiple encounters with one health professional or encounters with multiple health professionals constitute a single visit if all of the following conditions are satisfied:

(i) All encounters take place on the same day;

(ii) All contact involves a single PPS service; and

(iii) The service rendered is for a single purpose, illness, injury, condition, or complaint.

(b) Multiple encounters constitute separate visits if one of the following conditions is satisfied:

(i) The encounters involve different PPS services; or

(ii) The services rendered are for different purposes, illnesses, injuries, conditions, or complaints or for additional diagnosis and treatment.

(2) A visit may take place at an FQHC or RHC site, in a patient's home, at a related off-site location, or (for transportation) between an FQHC or RHC site and a patient's home or a related off-site location.

(3) A visit may be conducted through telehealth if the service is rendered in accordance with rule 5160-1-18 of the Administrative Code.

(4) No service provided to anyone other than a patient may be claimed as a visit with that patient.

(5) The following activities are not visits:

(a) Participation in a meeting or group session at which no health service is provided, such as an orientation session for new patients, a health presentation to a community group, or an informational presentation about a program managed by an FQHC or RHC;

(b) Provision of a health service as part of a community service program such as a mass immunization, a large group screening, or a health fair;

(c) A service rendered by a practitioner who is not employed by nor under contract with an FQHC or RHC; and

(d) A non-PPS service.

Last updated March 25, 2024 at 9:15 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 7/1/2027
Prior Effective Dates: 10/15/2001, 5/1/2005

Rule 5160-28-02 | FQHC and RHC services: conditions affecting medicaid provider participation.

• Effective: July 1, 2022
• Promulgated Under: 119.03

(A) Unless otherwise noted, any stipulations or limitations specified in the Revised Code or in agency 5160 of the Administrative Code apply to services rendered by a federally qualified health center (FQHC) or rural health clinic (RHC). Provisions of other rules in agency 5160 of the Administrative Code that concern coordination of benefits apply to payment for FQHC and RHC services.

(B) Responsibilities of an FQHC.

(1) When it enrolls or changes its enrollment (e.g., adds a service), an FQHC submits to the Ohio department of medicaid (ODM) a copy of a notice of authorization or notice of look-alike designation it has received from the federal health resources and services administration (HRSA). In particular, two pieces of documentation are needed:

(a) Confirmation that the FQHC satisfies HRSA criteria for providing the PPS services it plans to render (either new services or services added through a change in scope); and

(b) A list of the services approved by HRSA for the FQHC to perform at any of its sites.

(2) Each FQHC site obtains and uses its own medicaid provider number. No FQHC site is allowed to use the provider number of another FQHC site, even if the two share the same parent organization.

(3) The responsibility of an FQHC to pay a health professional for performing a service is described in a written agreement between the FQHC and the health professional.

(4) An FQHC notifies ODM in writing not later than ninety days after any permanent decrease in its scope of service.

(C) Medicaid payment cannot be made before the date listed on the FQHC HRSA notice or before the RHC certification date.

(D) No provider can be simultaneously enrolled in medicaid as both an FQHC and an RHC.

Last updated March 25, 2024 at 9:15 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2027
Prior Effective Dates: 11/10/1983, 6/1/1991, 3/1/2002

Rule 5160-28-03 | FQHC and RHC services: covered services, limitations, and copayments.

• Effective: July 1, 2022
• Promulgated Under: 119.03

(A) A federally qualified health center (FQHC) may receive prospective payment system (PPS) payment for providing any of the following FQHC PPS services:

(1) In accordance with section 330 of the Public Health Services Act, 42 U.S.C. chapter 6A (October 1, 2021), medical services, which comprise any of four types of services:

(a) Services referenced at 42 U.S.C. 1395x(aa)(3) (October 1, 2021), including but not limited to an evaluation and management (E&M) service, another medical or surgical procedure, or the administration of a vaccine or other provider-administered pharmaceutical;

(b) Professional services (including the administration of a vaccine) furnished by a qualified healthcare practitioner (physician, physician assistant, advanced practice registered nurse, dietitian, pharmacist, registered nurse working under supervision), along with any services or supplies furnished incident to the professional services on the same date;

(c) Professional services and related supplies provided at a later date as necessary follow-up to a medical services visit, even if the same services and supplies were also provided as part of (or incident to) the original medical services visit; or

(d) Visiting nurse services if the following three conditions are satisfied:

(i) The services are furnished by either a registered nurse or a licensed practical nurse employed by or under contract with the FQHC;

(ii) The FQHC is located in an area determined by the centers for medicare and medicaid services (CMS) to have a shortage of home health agencies; and

(iii) The services are furnished under a written plan of treatment that is established by a physician, physician assistant, or advanced practice registered nurse or by a supervising physician of the FQHC; is signed by a physician, physician assistant, or advanced practice registered nurse or by a supervising physician of the FQHC; and is reviewed at least every sixty days by a supervising physician of the FQHC.

(2) Dental services, which are identified in Chapter 5160-5 of the Administrative Code and to which the following conditions apply:

(a) An FQHC reports every dental procedure or service, in the appropriate claim format, as a PPS service; and

(b) For each set of dentures, an FQHC may submit one claim for providing the service and not more than two additional claims for follow-up visits;

(3) Physical therapy services or occupational therapy services, which are identified in Chapter 5160-8 of the Administrative Code;

(4) Behavioral health services identified in rule 5160-8-05 of the Administrative Code;

(5) Speech pathology and audiology services, which are identified in Chapter 5160-8 of the Administrative Code;

(6) Podiatry services, which are identified in Chapter 5160-7 of the Administrative Code;

(7) Vision services, which are identified in Chapter 5160-6 of the Administrative Code, that are rendered by a non-physician;

(8) Chiropractic services, which are identified in Chapter 5160-8 of the Administrative Code; or

(9) Transportation services that enable an individual to make up to four trips to or from an FQHC site (or related location) where a covered service is rendered on the same date.

(B) A rural health clinic (RHC) may receive PPS payment for providing any of the following RHC PPS services:

(1) Medical services, which comprise any of three types of services:

(a) All services referenced at 42 U.S.C. 1395x(aa)(1) (October 1, 2021), including but not limited to an evaluation and management (E&M) service, another medical or surgical procedure, or the administration of a vaccine or other provider-administered pharmaceutical;

(b) Professional services (including the administration of a vaccine) furnished by a qualified healthcare practitioner (e.g., physician, physician assistant, advanced practice registered nurse, dietitian, pharmacist, registered nurse working under supervision), along with any services or supplies furnished incident to the professional services on the same date;

(c) Professional services and related supplies provided at a later date as necessary follow-up to a medical services visit, even if the same services and supplies were also provided as part of (or incident to) the original medical services visit;

(2) Behavioral health services identified in rule 5160-8-05 of the Administrative Code; or

(3) Transportation services that enable an individual to make up to four trips to or from an RHC (or related location) where a covered service is rendered on the same date.

(C) An FQHC or RHC may structure its enrollment in medicaid such that it can submit a claim and receive separate payment for a covered service or supply that cannot be claimed as a PPS service under paragraphs (A) and (B) of this rule.

(1) No PPS service may be claimed as a non-PPS service. Payment for a covered non-PPS service is made in accordance with the rule or chapter of the Administrative Code that applies to the service.

(2) The following non-exhaustive list specifies covered medically necessary services and supplies that may be claimed as non-PPS services:

(a) Group therapy;

(b) Remote patient monitoring;

(c) Acupuncture rendered by an acupuncturist;

(d) Inpatient hospital services;

(e) Take-home medications;

(f) Hemophilia clotting factor drugs;

(g) Long-acting reversible contraception (LARC);

(h) Durable medical equipment for take-home use;

(i) The technical component of a procedure comprising both a professional and a technical component, such as radiography or other imaging;

(j) Clinical diagnostic laboratory services other than the following procedures:

(i) Venipuncture;

(ii) Chemical examination of urine by stick or tablet method or both;

(iii) Hematocrit or hemoglobin analysis;

(iv) Blood sugar analysis;

(v) Examination of stool specimens for occult blood;

(vi) Pregnancy tests; and

(vii) Primary culturing for transmittal to a certified laboratory;

(k) Eyeglass lenses and frames;

(l) Topical fluoride varnish furnished by a non-dental practitioner in accordance with rule 5160-4-33 of the Administrative Code;

(m) A vaccine administered as part of a mass immunization;

(n) A report of a pregnancy that is diagnosed in conjunction with a PPS service, described in rule 5160-21-04 of the Administrative Code;

(o) A pregnancy risk assessment, described in rule 5160-21-04 of the Administrative Code; and

(p) Behavioral health services and substance use disorder services identified in Chapter 5160-27 of the Administrative Code that meet the following criteria:

(i) They cannot be claimed as PPS services; and

(ii) They are rendered by certified behavioral health practitioners in accordance with Chapter 5160-27 of the Administrative Code and federal and state law.

(3) The provision of a covered non-PPS service on the same date as a covered PPS service does not preclude payment for either service.

(D) Copayments established in accordance with rule 5160-1-09 of the Administrative Code may apply to services rendered by an FQHC or RHC. Copayments for services rendered to MCE members are applied in accordance with applicable medicaid rules in the Administrative Code concerning MCEs.

Last updated March 25, 2024 at 9:16 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.20, 5164.02
Five Year Review Date: 7/1/2027
Prior Effective Dates: 3/1/2002

Rule 5160-28-04 | FQHC and RHC services: submission of a cost report.

• Effective: July 1, 2022
• Promulgated Under: 119.03

(A) Data entered into a cost report should represent "reasonable and allowable costs," which are defined in "Principles of reasonable cost reimbursement," 42 C.F.R. part 413 (October 1, 2021).

(B) For purposes of payment determination, an FQHC or RHC submits a cost report in any of the following circumstances:

(1) An FQHC or RHC that is newly enrolled as a medicaid provider submits a cost report covering the twelve-month period beginning either on the first day of the first calendar month or on the first day of the first full fiscal year after enrollment.

(2) An FQHC or RHC that requests an adjustment of a per-visit payment amount (PVPA) based on a change in scope of an existing FQHC or RHC PPS service submits a cost report for that service covering the twelve-month period beginning either on the first day of the first calendar month or on the first day of the first full fiscal year after the change in scope. If the adjustment is granted, the PVPA derived from the cost report becomes the new PVPA.

(3) An FQHC or RHC that has chosen to provide an additional PPS service (other than transportation) submits a cost report for that service covering the twelve-month period beginning either on the first day of the first calendar month or on the first day of the first full fiscal year after addition of the service.

(4) A government-operated FQHC that requests the alternate payment method (APM) described in rule 5160-28-07.1 of the Administrative Code submits cost reports in accordance with that rule.

(C) The Ohio department of medicaid (ODM) or its designee may perform a desk review or conduct a field audit of any cost report submitted and may request any supporting documentation it deems necessary.

(D) No extension will be granted for submission of cost reports. If an FQHC or RHC fails to submit a complete and accurate cost report within one hundred twenty days after the end of a reporting period, ODM may choose to take either or both of two courses of action:

(1) It may decline to make any adjustments to the established PVPA or PVPAs.

(2) It may impose a penalty of not more than five hundred dollars for each business day on which the cost report is late.

(E) An FQHC or RHC may request adjustment of a PVPA.

(1) In its request, it addresses in writing the following topics:

(a) It specifies the basis for the request, such as a change in scope of an existing service or the addition of a new service.

(b) It specifies which cost centers have been affected and why.

(c) It describes the steps it took to arrive at the conclusion that an adjustment would be the most efficient means of responding to cost changes.

(d) It provides documentation to support its request, such as a community needs assessment or other analysis.

(e) If the change in scope is directly attributable to a change in the intensity of services provided, then the FQHC or RHC provides evidence such as a change in the acuity of care caused by a shift in the distribution of diagnoses or a change in the relative-value components of the services provided.

(f) An FQHC that is adding a PPS service submits to ODM a copy of the notice of grant award authorization from the federal health resources and services administration (HRSA) confirming that its sites satisfy HRSA criteria for providing the new PPS service it plans to render.

(2) ODM has sole discretion over whether to grant a request for adjustment of a PVPA.

(F) ODM will respond in writing within sixty days after it receives a request for an adjustment of a PVPA based on a change in scope or after it receives additional information needed to determine whether an adjustment is warranted.

(G) The following conditions apply to any adjustment of a PVPA based on a change in scope:

(1) Such an adjustment can be granted only once for a particular circumstance for a particular FQHC or RHC service site.

(2) No adjustment will be made if the percentage of change represented by the calculated PVPA for the service is not at least twice the medicare economic index (MEI) for the relevant year.

(3) No adjusted PVPA may exceed any limit, ceiling, or other maximum set forth in agency 5160 of the Administrative Code.

Last updated March 25, 2024 at 9:16 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2027
Prior Effective Dates: 10/25/2001

Rule 5160-28-05 | FQHC and RHC services: prospective payment system (PPS) method for determining payment.

• Effective: July 1, 2022
• Promulgated Under: 119.03

(A) A discrete, all-inclusive per-visit payment amount (PVPA) is established for each FQHC PPS service provided at an FQHC or related off-site location and for an RHC PPS service provided at an RHC or related off-site location.

(1) For all FQHC or RHC sites that are already enrolled as medicaid providers, ODM establishes new PVPAs equal to the current PVPAs revised to reflect the latest available medicare economic index (MEI) percentage. The new PVPAs are established by October first of each year and are in effect from October first through the following September thirtieth.

(2) When an enrolled FQHC or RHC site requests adjustment of a PVPA, ODM may establish a new PVPA based on a cost report in accordance with rule 5160-28-04 of the Administrative Code.

(3) For an FQHC or RHC site that is enrolling as a new medicaid provider or an FQHC site that is adding a new FQHC PPS service, ODM establishes an initial PVPA in accordance with the following procedure:

(a) First, the initial PVPA is set equal to the corresponding PVPA of other FQHC or RHC sites in the immediate area that are similar in size, caseload, and scope of services. If no such FQHC or RHC site exists, then the initial PVPA is set equal to the current PVPA at the applicable statewide sixtieth percentile for the appropriate FQHC or RHC classification (FQHC or RHC).

(b) This initial PVPA remains in effect until a new PVPA is established.

(c) After the initial PVPA is set, the FQHC or RHC site submits a cost report in accordance with rule 5160-28-04 of the Administrative Code. A new PVPA is established on the basis of the cost report and is revised to reflect any changes in the MEI that have occurred since the cost report was submitted.

(d) Thereafter, the PVPA is revised in accordance with paragraph (A)(1) of this rule.

(4) For an FQHC PPS service only, if no current PVPA at the applicable statewide sixtieth percentile is available, then the initial PVPA, P, is obtained by the formula P = M (S / E), rounded up to the next whole dollar.

(a) M is the greater of two figures:

(i) The current PVPA for medical services at the applicable statewide sixtieth percentile for FQHC sites; or

(ii) The current PVPA for medical services at the particular FQHC site.

(b) S is the medicaid maximum payment amount (or the median of the medicaid maximum payment amounts) for a procedure (or a group of procedures) typical of the service for which a PVPA is being established.

(c) E is the medicaid maximum non-facility payment amount for a mid-level evaluation and management service (office visit) for an established patient.

(B) A PVPA based on a cost report is effective from the first day of the first full calendar month after ODM has established or adjusted the PVPA through the following September thirtieth. A PVPA that is established or adjusted before September thirtieth and becomes effective on or after October first is then further revised to reflect the applicable MEI. No retroactive establishment or adjustment will be made for a PVPA.

(C) A PVPA is specific to an FQHC or RHC site. No FQHC or RHC site may submit claims based on the PVPAs of another FQHC or RHC site.

(D) Decisions of ODM with respect to the establishment or adjustment of a PVPA are not subject to Chapter 119. of the Revised Code.

Last updated April 2, 2024 at 2:21 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2027
Prior Effective Dates: 10/15/2001, 10/1/2016

Rule 5160-28-06.1 | FQHC and RHC services: limits on a per-visit payment amount (PVPA) determined on the basis of a cost report for an FQHC PPS service.

• Effective: July 1, 2022
• Promulgated Under: 119.03

(A) Allowable costs are calculated in accordance with the instructions for the federally qualified health center (FQHC) cost report. Certain restrictions apply:

(1) Costs related to direct inpatient care are not allowable.

(2) Procedures or items that are not PPS services are not allowable.

(3) The straight-line method of computing depreciation is used for all depreciable assets.

(4) The cost claimed for services, facilities, and supplies furnished by a related organization cannot exceed the lesser of two figures:

(a) The cost to the related organization; or

(b) The price of comparable services, facilities, or supplies that are generally available in the competitive marketplace.

(5) Total allowable administrative and general overhead costs cannot exceed thirty-five per cent of the costs of the services to which they are applied. Of these costs, not more than thirty thousand dollars are allowable annually as recruitment cost incurred by a provider of FQHC medical service.

(B) Limits are established by applying tests of reasonableness to the allowable costs.

(1) For each PPS service except transportation, a limit is established by dividing the allowable cost by the greater of two figures:

(a) The total number of visits; or

(b) The product of the actual number of direct hours worked by the professional and the applicable number of visits per hour from the following list:

(i) Physician services, per physician 2.4;

(ii) Physician assistant or advanced practice registered nurse services, per practitioner 1.2;

(iii) Dental services 1.8;

(iv) Physical therapy services 2.0;

(v) Behavioral health services or substance use disorder services 0.7;

(vi) Speech pathology and audiology services 1.8;

(vii) Podiatry services 2.4;

(viii) Vision services 1.9;

(ix) Chiropractor services 2.4. and

(x) Occupational therapy services 2.0;

(2) For transportation, a limit is established of twenty-five dollars per unit of service.

(C) A ceiling is established for each PPS service at one hundred twenty per cent of the statewide sixtieth percentile PVPA.

(D) The final PVPA for an FQHC PPS service is the least of the allowable cost, the limit, or the ceiling.

Last updated April 2, 2024 at 2:21 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2027
Prior Effective Dates: 7/1/2006

Rule 5160-28-07.1 | FQHC and RHC services: alternate payment method (APM) for determining payment for government-operated FQHCs.

• Effective: July 1, 2022
• Promulgated Under: 119.03

(A) This rule describes an alternate payment method (APM) that may be selected, with approval from the Ohio department of medicaid (ODM), by a government-operated federally qualified health center (FQHC) such as a public health department. Under this APM, a government-operated FQHC may receive payment in addition to amounts established under the prospective payment system (PPS) method described in rule 5160-28-05 of the Administrative Code. To qualify for additional payment under this APM, a government-operated FQHC site submits both a preliminary cost report and a fully audited cost report for every cost-reporting period. For purposes of this rule, a cost-reporting period is the fiscal year used by the government-operated FQHC. For a government-operated FQHC that has newly selected the APM, ODM may agree to an initial cost-reporting period covering not less than six months nor more than seventeen months.

(B) The APM involves two steps:

(1) Submission of an annual cost report. Within one hundred twenty days after the close of its fiscal year, the government-operated FQHC site compiles and submits a fully audited cost report of all PPS services rendered during that cost-reporting period. Government-operated FQHC sites of the same parent organization compile and submit separate cost reports. When it submits its annual cost report, the government-operated FQHC site attests 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.

(2) Calculation of an APM payment. After it receives an audited cost report and certification, ODM performs a desk review of the cost report and determines the amount for which the government-operated FQHC site is eligible to receive payment, in the form of federal matching funds, in addition to amounts established under the PPS. The cost report is not used in any way to alter amounts established under the PPS.

(a) No additional limitation, test of reasonableness, or ceiling described in rule 5160 28-06.1 of the Administrative Code is applied to the cost report. The resulting figures represent the total actual allowable costs during the cost-reporting period.

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

(c) For each PPS service, the "total allowable medicaid cost" for the cost-reporting period is the product of the average cost per visit and the number of visits made by medicaid-eligible individuals.

(d) The "total medicaid payment" for a PPS service during the cost-reporting period is the sum of the per-visit payment amounts (PVPAs) paid to an FQHC site under the prospective payment system (PPS), payments made by MCEs, and medicaid wraparound payments.

(e) The "total medicaid variance" for a PPS service is the difference obtained by subtracting the total medicaid payment from the total allowable medicaid cost. If this difference is positive, ODM calculates the federal share of the difference by applying the appropriate federal match percentage and then remits this amount to the government-operated FQHC site.

(C) For payment purposes, the federal share amounts for the various PPS services offered at an FQHC site may be aggregated.

Last updated April 2, 2024 at 2:21 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2027

Rule 5160-28-12 | Establishment of a per-visit payment amount (PVPA) derived from a cost report submitted by a federally qualified health center (FQHC) or rural health clinic (RHC) site affected by a public health emergency (PHE) declaration.

• Effective: December 27, 2021
• Promulgated Under: 119.03

(A) The purpose of this rule is to allow a change to the time period of a cost report from which per-visit payment amounts (PVPAs) are derived. This rule applies to cost report time periods affected by a nationwide federal or Ohio public health emergency (PHE) declaration.

(B) This rule applies to a cost report prepared by an individual federally qualified health center (FQHC) or rural health clinic (RHC) site in accordance with this chapter of the Administrative Code for one of the following reasons:

(1) The FQHC or RHC is newly enrolled as a medicaid provider; or

(2) The FQHC or RHC plans to request the establishment or adjustment of a PVPA based on a change in scope of a prospective payment system (PPS) service.

(C) The time period covered by the applicable cost report may be altered in one of the following ways:

(1) The length of the period is set at not less than eight consecutive months nor more than twelve consecutive months; or

(2) An alternate beginning date of the period is set by the Ohio department of medicaid in collaboration with the FQHC or RHC site.

Last updated December 27, 2021 at 5:46 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 12/27/2026
Prior Effective Dates: 8/19/2021 (Emer.)