Chapter 5160-28 Federally Qualified Health Center Services

5160-28-01 Federally qualified health centers (FQHCs): eligibility and enrollment as a medicaid provider.

(A) A federally qualified health center (FQHC)is:

(1) An entity that has entered into an agreement with the centers for medicare and medicaid services (CMS) to meet medicare program requirements and is receiving a grant under section 330 of the Public Health Service Act or is receiving funding from such a grant under a contract with the recipient of such a grant and meets the requirements to receive a grant under section 330 of the Public Health Service Act.; or

(2) An FQHC look-alike, based on the recommendation of the public health service, determined by CMS to meet all the eligibility requirements of an entity to receive a grant under section 330 of the Public Health Service Act, but does not receive grant funding.

(B) An FQHC, as determined in accordance with paragraph (A)(1) of this rule, must submit to the department appropriate documentation that each service site provides services in accordance with the provisions of section 330 of the Public Health Services Act. Appropriate documentation is any documentation from the health resources and services administration (HRSA) that identifies the specific service site(s) included in the 330 public health services project.

(C) An FQHC, as determined in accordance with paragraph (A)(2) of this rule, must submit to the department a copy of the U.S. secretary of health and human services confirmation letter that the service site(s) meet(s) the requirements for receiving a grant under section 330 of the Public Health Service Act and will be considered an FQHC look-alike with respect to medicaid coverage and payment.

(D) An FQHC, as defined in accordance with paragraph (A)(1) of this rule, will be reimbursed as an FQHC in accordance with Chapter 5101:3-28 of the Administrative Code. An FQHC, as defined in accordance with paragraph (A)(2) of this rule, will be reimbursed as an FQHC for services provided on and after the date the U.S. secretary of health and human services approval is received by the department.

(E) Providers may be enrolled as only one type of alternative payment clinic. An "alternative payment clinic" shall be defined as an FQHC, rural health clinic (RHC), or outpatient health facility (OHF).

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: 4/10/91, 3/1/02

5160-28-02 Federally qualified health centers (FQHCs): covered services.

(A) "Covered core services" FQHCs are those:

(1) Medical services furnished by a physician, physician assistant, or advanced practice nurse (as described in rules 5101:3-8-20 to 5101:3-8-23 of the Administrative Code, except for an advanced practice nurse providing services relating to mental health services as defined in paragraph (B)(8) of this rule). The services must be within the scope of practice of his or her profession under state law. There must be a written agreement between the FQHC and the health professional stating that he or she will be paid by the FQHC for such services.

(2) Services and supplies furnished as an incident to professional services furnished by a physician, physician assistant, or advanced practice nurse.

(3) Visiting nurse services if:

(a) The service site 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, a licensed practical nurse employed by, or otherwise compensated for the services by, the FQHC;

(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 FQHC or that is established by a physician, physician assistant, or advanced practice nurse and reviewed at least every sixty days by a supervising physician of the FQHC and signed by the physician, physician assistant, or advanced practice nurse or supervising physician.

(B) "Covered noncore services" for FQHCs are those services, other than core services, that include the following:

(1) Physical therapy services;

(2) Speech pathology and audiology services;

(3) Dental services;

(4) Podiatry services;

(5) Optometric and/or optician services;

(6) Chiropractic services;

(7) Transportation services; and,

(8) Mental health services in accordance with the limitations specified in rule 5101:3-28-03 of the Administrative Code.

(C) Services listed in paragraph (C) of rule 5101:3-28-04 of the Administrative Code are not FQHC covered services. FQHCs shall bill the department for these services in accordance with paragraph (C) of rule 5101:3-28-04 of the Administrative Code.

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: 4/10/91, 3/1/02

5160-28-03 Federally qualified health centers (FQHCs): coverage and limitation policies.

(A) Covered core medical services for FQHCs are:

(1) "Physician services," as defined in Chapter 5101:3-4 of the Administrative Code. The limitations found in the physician chapter also apply to physician services furnished under the auspices of an FQHC.

(2) "Physician assistant services," as defined in Chapter 5101:3-4 of the Administrative Code. The limitations found in the physician chapter also apply to physician assistant services furnished under the auspices of an FQHC.

(3) "Advanced practice nurse services," as defined in rule 5101:3-8-23 of the Administrative Code, except for services relating to mental health as defined in paragraph (B)(8) of this rule, provided by an advanced practice nurse as defined in rules 5101:3-8-20 to 5101:3-8-23 of the Administrative Code. The limitations found in rule 5101:3-8-23 of the Administrative Code also apply to advanced practice nurse services provided under the auspices of an FQHC.

(4) "Services and supplies furnished as incident to professional services by a physician, physician assistant, advanced practice nurse, clinical social worker, or psychologist" are those services and supplies that are commonly furnished in physicians' offices; and commonly rendered without charge or included in the physician visit charge or provided as an incidental but integral part of the physician's services provided under the direct supervision of a physician as described in paragraph (A)(1) of rule 5101:3-4-02 of the Administrative Code; and, furnished by an employee of the clinic.

(B) Covered noncore services for FQHCs are:

(1) "Physical therapy services" are those services identified in rule 5101:3-1-60 of the Administrative Code. These services must be provided in accordance with the physical therapy licensure requirements found in Chapter 4755. of the Revised Code. Limitations found in rule 5101:3-8-02 of the Administrative Code also apply to services rendered in an FQHC.

(2) "Speech pathology and audiology services" are those services identified in rule 5101:3-1-60 of the Administrative Code. These services must be provided in accordance with the licensure requirements found in Chapter 4753. of the Revised Code. Limitations found in Chapter 5101:3-13 of the Administrative Code also apply to services rendered by an FQHC.

(3) "Dental services," as defined in Chapter 5101:3-5 of the Administrative Code. Limitations found in the dental chapterChapter 5101:3-5 of the Administrative Code also apply to dental services rendered under the auspices of an FQHC, with the exception of denture services. Full and partial dentures shall be prior authorized by the department. For dates of service on and after the effective date of this rule, FQHCs may submit up to three claims for the provision of dentures, including not more than two follow-up encounters. Follow-up visits shall be medically necessary for the provision of full or partial dentures.

(4) "Podiatry services" are those services identified in Chapter 5101:3-7 of the Administrative Code. Limitations found in Chapter 5101:3-7 of the Administrative Code also apply to podiatry services rendered under the auspices of an FQHC.

(5) "Optometric and/or optician services" are those services identified in Chapter 5101:3-6 of the Administrative Code. Limitations found in Chapter 5101:3-6 of the Administrative Code also apply to vision services rendered under the auspices of an FQHC. Services rendered by an ophthalmologist are physician services and considered a core service.

(6) "Chiropractic services" are those services identified in rule 5101:3-8-11 of the Administrative Code. Limitations found in rule 5101:3-8-11 of the Administrative Code also apply to chiropractic services rendered under the auspices of an FQHC.

(7) "Transportation services" are those instances of transportation to and/or from a medicaid service site of an FQHC. The transportation must be provided on the same date as another Medicaid covered encounter occurs;.

(8) "Mental health services" are those services provided by a clinical psychologist or advanced practice nurse certified by a national-certifying organization in the specialty of psychiatry in accordance with Chapter 5101:3-8 of the Administrative Code and services provided by a licensed social worker, clinical social worker, professional counselor, professional clinical counselor, in accordance with rule 5101:3-4-29 of the Administrative Code. FQHCs shall be able to bill Medicaid for therapy and testing. The limitations found 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 FQHC.

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

(D) 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 FQHC. Specific information regarding implementation of co-payments in managed care settings are located in Chapter 5101:3-26 of the Administrative Code.

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 , 5111.0112 , 5111.02 , 5111.021
Prior Effective Dates: 4/10/91, 3/1/02

5160-28-04 Federally qualified health centers (FQHCs): billable services.

(A) "Billable services" for FQHCs are core and noncore services identified in rule 5101:3-28-02 of the Administrative Code which areand provided in accordance with Chapter 5101:3-28 of the Administrative Code.

(B) Services shall be billed on an encounter basis. An "encounter" is defined as face-to-face contact between a patient and provider(s) of covered core or covered noncore services, except for transportation services.

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

(2) The services of a registered nurse shall be billed as a medical encounter unless provided "incident to" a medical encounter as described in paragraph (B)(3) of this rule.

(3) Encounters with more than one health professional for the same type of service (e.g., a nurse and a physician provide a medical 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 and treatment.

(4) Each type of service, as set forth in paragraphs (A)(1) to (A)(3) and (B) of rule 5101:3-28-03 of the Administrative Code, is separately billable regardless of whether the encounters occur on separate days or the same day(e.g., a physician and a dentist provide different types of services).

(5) "Billable encounters" are encounters that:

(a) Take place at a service site approved by public health services as part of an FQHC; or

(b) Take place in a patient's home or outpatient hospital setting for the purpose of providing services to FQHC patients; and

(c) Are documented in the patient health records in accordance with rule 5101:3-1-27 of the Administrative Code.

(6) For dates of service on and after the effective date of coverage of denture follow-up encounters in accordance with paragraph (B)(3) of rule 5101:3-28-03 of the Administrative Code, to receive reimbursement for a denture follow-up encounter, the FQHC shall submit a claim with the following information:

(a) Enter the code T1015 modified by U2 to indicate this is a billing for dental services.

(b) On the next line of the claim, bill D0140 modified by TS to indicate that this is a follow-up visit for a denture service that was previously prior authorized by the department.

(7) Transportation services shall be billed on a unit basis. Each trip to or from the service site shall be counted as a unit of transportation service.

(8) Consultations with anyone other than the patient are not considered encounters, and are therefore not billable.

(9) Each FQHC service site must obtain and use its own separate medicaid provider number.

(a) An FQHC service site may not use the provider number of another FQHC service site, even another service site within the parent organization.

(b) Services provided away from the FQHC service site, such as in an individual's home, must be associated with a specific FQHC service site and must be billed using the provider number of the FQHC service site held accountable for the delivery of the services.

(C) The following services are not billable under a provider's FQHC provider number. These services should be billed by an FQHC under a different medicaid provider number as a fee-for-service ambulatory care 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 as described in Chapter 5101:3-10 of the Administrative Code.

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: 4/10/91, 3/1/02

5160-28-07 Federally qualified health centers (FQHCs): 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 federally qualified health center(FQHC) for services provided by the FQHC to a medicaid recipient enrolled in the MCP.

(2) "Encounter" is defined in rule 5101:3-28-04 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, FQHCs that have received payment from an MCP for FQHC services identified in rule 5101:3-28-02 of the Administrative Code are eligible to receive a supplemental payment from the department if the amount the FQHC was paid by an MCP for services provided to an MCP enrollee is less than the amount the FQHC would have received under the prospective payment system(PPS) reimbursement method described in rule 5101:3-28-08 of the Administrative Code.

(C) For services furnished for the period January 1, 2001 to June 30, 2001, FQHCs were eligible to submit quarterly requests for supplemental payments.

(D) Effective for services furnished on and after July 1, 2001 through September 30, 2003, to receive the supplemental payment for an encounter provided to aan MCP enrollee, an FQHC must submit a claim to the department following the Ohio medicaid provider billing instructions utilized by FQHCs for fee-for-service medicaid consumers with third party insurance.

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

(a) The encounter code T1015 and the appropriate modifier to signify the type of encounter provided by the FQHC; and,

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

(2) FQHCs 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 provider number of the MCP that paid the FQHC in the referring physician field; and

(c) The sum of the dollar amount the FQHC 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 FQHC from any other third party insurance.

(E) For services provided on or after October 1, 2003, to receive the supplemental payment, an FQHC must bill for services as outlined in rule 5101: 3-28-11 of the Administrative Code. The data elements submitted for a supplemental payment claim are dependent on whether the claim is a paper claim or an electronic transaction:

(1) If the FQHC chooses to submit a paper claim, submit the data elements outlined in paragraph (D) of this rule except instead of billing the codes to signify the type of encounter, follow the instructions in rule 5101:3-28-11 of the Administrative Code.

(2) If the FQHC chooses to submit an electronic transaction, use the 837 transaction. Report the data elements unique for supplemental claims:

(a) Enter the name of the MCP provider under the "other payer name" field;

(b) Enter the "identification code" of the other payer (the MCP) that initially paid for the services. The identification code is assigned by Ohio medicaid; and

(c) Enter the sum of the dollar amount the FQHC was paid by the MCP for the 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. Enter this amount as the "monetary amount" in the "other payer" area.

(F) Calculation of supplemental payments:

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

(2) For dates of service on and after July 1, 2001, upon receipt of the claim the department will pay any difference between the amount paid by the MCP to the FQHC and the amount due the FQHC based on its PPS rate approved by the department for the specific claim submitted. These payments will occur no less frequently than every four months.

The department's supplemental payment obligation will be determined using the baseline payment that the FQHC would have received under PPS reimbursement as described in rule 5101:3-28-08 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.

(G) If a claim is not submitted by an FQHC 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 FQHC.

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: 8/9/01, 10/1/03

5160-28-08 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

5160-28-08.1 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

5160-28-09 Federally qualified health centers (FQHCs): prospective payment system (PPS) rate review for change in scope of service.

This rule describes the two methods for determining PPS rates for a change in scope of service.

(A) Definitions.

(1) "Change in scope of service" means:

(a) The addition or deletion of a new category of service as described in paragraph (B) of this rule; or

(b) The department has granted a request filed by an FQHC that a service has changed in scope as specified in paragraph (C) of this rule.

(2) "Category of service" means the following different types of services:

(a) Medical, as defined in Chapter 5101:3-4 of the Administrative Code;

(b) Dental, as defined in Chapter 5101:3-5 of the Administrative Code;

(c) Mental health, as defined in rule 5101:3-8-05 and 5101:3-4-29 of the Administrative Code;

(d) Physical therapy, as defined in rule 5101:3-8-02 of the Administrative Code;

(e) Podiatry, as defined in Chapter 5101:3-7 of the Administrative Code;

(f) Optometry, as defined in Chapter 5101:3-6 of the Administrative Code;

(g) Chiropractic, as defined in Chapter 5101:3-11 of the Administrative Code;

(h) Speech pathology and audiology, as defined in Chapter 5101:3-13 of the Administrative Code; and

(i) Transportation, as defined in Chapter 5101:3-15 of the Administrative Code.

(3) "Increase or decrease in the scope of services" means the addition or deletion of a category of service or the department has granted a request filed by an FQHC that a service has changed in scope as specified in paragraph (C) of this rule.

(B) Method one:

A routine change in scope of service is the addition or deletion of a new category of service as defined in paragraph (A) of this rule. The following methodology will be used to establish the rate for a service type that meets the provisions in paragraph (A)(1)(a) of this rule.

(1) As an interim step, FQHCs that establish a new category of service will be given a start-up rate for the new category of service. The start-up rate for urban FQHCs will be the sixtieth percentile for urban FQHCs offering that category of service in accordance with paragraph (C) of rule 5101:3-28-08 of the Administrative Code. For rural FQHCs, the start-up rate will be the sixtieth percentile for rural FQHCs offering that category of service in accordance with paragraph (C) of rule 5101:3-28-08 of the Administrative Code. This interim rate will be in effect until a rate for that FQHC for that category of service is established by the department based on the methodology described in paragraphs (B)(3) to (B)(7) of this rule.

(2) FQHCs adding a new category of service must file a cost report in accordance with the instructions in JFS 03421 (07/2001) and rule 5101:3-28-10 of the Administrative Code:

(3) Upon receipt of a complete and accurate cost report, the department will review the FQHC's costs for the service that has changed in scope of service and will adjust the PPS rate based on the reasonable cost parameters described in paragraphs (B)(4) to (B)(7) of this rule.

(4) General provisions for allowable and reasonable costs.

"Costs that are reasonable and related to patient care" are those contained in the following reference material in the following priority: 42 C.F.R. part 413 "principles of reasonable cost reimbursement" effective October 1, 2005; "centers for medicare and medicaid services (CMS) publication 15-1, provider reimbursement manual," available at www.cms.hhs.gov/manuals/ (rev. 1/2005); and "the American institute of certified public accountants (AICPA) Federal generally accepted accounting principles (GAAP) hierarchy statement on auditing standards (SAS) No. 91 (1999)," except that:

(a) Costs related to patient care and services that are not covered under the FQHC program as described in Chapter 5101:3-28 of the Administrative Code are not allowable.

(b) The straight line method of computing depreciation is required for cost filing purposes, and it must be used for all depreciable assets.

(c) For purposes of determining allowable and reasonable cost in the purchase of goods and services from a related party, the following definition of related shall be used: "related" is one who enjoys, or has enjoyed within the previous five years, any degree of another business relationship with the owner or operator of the facility, directly or indirectly, or one who is related by marriage or birth to the owner or operator of the facility.

(d) Upper limits for costs associated with related party transactions are defined as the following:

(i) FQHCs are required to identify all related organizations; i.e., related to the FQHC by common ownership or control.

(ii) The cost claimed on the cost report for services, facilities, and supplies furnished by the related organization shall not exceed the lower of:

(a) The cost to the related organization; or

(b) The price of comparable services, facilities, or supplies generally available.

(e) Tests of reasonableness, ceilings and upper limits as identified in paragraphs (B)(5) to (B)(7) of this rule shall be applied in determining allowable and reasonable cost.

(5) Ceilings on administrative and general costs.

(a) A thirty-five per cent ceiling for total allowable administrative and general and overhead costs shall be applied to all services. Total allowable administrative and general and overhead costs are defined as costs reported on the JFS 03421, schedule C-1, part II and schedule C-2 parts III and IV, plus any allowable costs to these costs areas from schedule C-1, part I of the JFS 03421.

(b) An annual exemption of thirty thousand dollars per year per provider from the ceiling on administrative and general costs is allowable for the recruitment costs of core providers.

(6) Tests of reasonableness for professional services and transportation. Allowable costs reported to the department in accordance with the instructions for the JFS 03421 will be adjusted based on minimum required efficiency standards calculated as encounters per hour. The rate established for the following service components will not exceed the lower of the rates as determined by dividing allowable costs by allowable encounters or allowable costs divided by the product of direct hours worked by the professional and the encounters per hour as shown:

(a) Physician services - 2.4 encounters per hour per physician;

(b) Physician assistant or advanced practice nurses services - 1.2 encounters per hours per practitioner;

(c) Mental health services in accordance with paragraph (B)(8) of rule 5101:3-28-02 of the Administrative Code -- .7 encounters per hour;

(d) Physical therapy services -- 2.0 encounters per hour;

(e) Speech pathology and audiology services -- 1.8 encounters per hour;

(f) Dental services -- 1.8 encounters per hour;

(g) Podiatry services -- 2.4 encounters per hour;

(h) Optometric and/or optician services -- 2.3 encounters per hour; and

(i) Chiropractor services -- 2.4 encounters per hour; and

(j) Transportation reimbursement shall not exceed:twenty-five dollars per one way unit of service to and/or from a medicaid covered FQHC service.

(7) Reimbursement rates shall not exceed the higher of the appropriate medicare ceiling or the wage adjusted ceilings on reimbursement rates as follows:

(a) Using as filed the JFS 03421 for each eligible FQHC site, an allowable cost per encounter for any new category of service shall be calculated. Tests of reasonableness, ceilings, and upper limits identified in paragraphs (B)(5) to (B)(7) of this rule shall be applied to the as filed cost of each eligible FQHC site prior to calculation of the percentile cost per encounter.

(b) The statewide urban sixtieth percentile cost per encounter is the sixtieth percentile of the values of all urban facilities receiving a grant under section 330 of the Public Health Service Act in accordance with paragraph (C) of rule 5101:3-28-08 of the Administrative Code. The statewide rural percentile cost per encounter is the sixtieth percentile of the values of all rural facilities receiving a grant under section 330 of the Public Health Service Act in accordance with paragraph (C) of rule 5101:3-28-08 of the Administrative Code.

(c) The urban wage adjustment factor is the adjustment factor for the FQHC's location obtained from the most recent Ohio wage index published in the Federal Register for the year in which the FQHC's rate is being established divided by the most recent Ohio rural wage index.

(d) The final ceilings on core and noncore service reimbursement for each rural facility is the statewide rural sixtieth percentile as set forth in paragraph (B)(7)(b) of this rule. The final ceilings on core and noncore service reimbursement for each urban facility is calculated by multiplying the statewide urban sixtieth percentile as set forth in paragraph (B)(7)(b) of this rule by the adjustment factor for the FQHC's wage adjustment factor described in paragraph (B)(7)(c) of this rule.

(e) The payment rate shall not exceed the higher of the medicare ceiling or wage adjusted ceilings for reimbursement rates as set forth in paragraph (B)(7)(d) of this rule.

(f) The final rate for the service that has changed in scope of service will be effective within sixty days of receipt of a complete and accurate cost report.

(C) Method two:

An FQHC also may request a review for a change in scope of service if none of the provisions in paragraph (A) of this rule apply.

(1) A change in scope of service may include but is not limited to the following:

(a) The addition of a service that has been mandated by a governmental entity such as the centers for medicare and medicaid services (CMS) in federal statute, rules, or policies enacted or amended after January 1, 2002;

(b) The addition of an obstetrical-gynecological physician or nurse mid-wife or other advanced practice nurse with a certification in obstetrical-gynecological services to an FQHC site that did not previously offer obstetrical services;

(c) The addition of a dentist to a site that only offered dental hygienist's services previously. The site did not previously employ a licensed dentist and did not offer the full scope of dental services; or

(d) An increase in the intensity of services provided.

(2) The following situations are not considered a change in scope of services:

(a) Wage increases;

(b) Negotiated union contracts;

(c) Renovations or other capital expenditures;

(d) The addition of a disease management program;

(e) An increase in the number of staff working in the clinic such as the addition of:

(i) A lower level staff member such a family nurse practitioner when a site employs a family physician.;

(ii) A hygienist when a dentist is employed at the site;

(iii) A physical therapy assistant when the site employs a physical therapist; and

(iv) Social service staff.;

(f) An increase in office space that is not directly associated with an approved change in scope of service, e.g., the addition of an obstetrical-gynecological physician;

(g) An increase in equipment or supplies that is not directly associated with an approved change in scope of service, e.g., the addition of an obstetrical-gynecological physician;

(h) An increase in patient volume; and

(i) An increase in office hours.

(3) An FQHC's request for a rate increase due to a change in scope of service will be granted at the sole discretion of the department. The calculated PPS rate for the service that changed in scope must increase by at least twice the MEI for that year before the department will grant the request for a change in scope of service.

(4) A rate review for a change in scope of service shall not increase a rate in excess of any rate limitations, ceilings, or tests of reasonableness set forth in division-level 5101:3 of the Administrative Code.

(5) A request for review of a change in scope of service must be filed no later than ninety days after the close of one year of operation of the service that has changed in scope.

(6) A rate adjustment due to a change in scope shall be granted only once for a particular circumstance for a particular FQHC.

(7) A request for rate review due to a change in scope of service must be filed in accordance with the following procedures:

(a) The request for review of a change in scope of service must be in writing.

(b) The request for a rate review must indicate that it is due to a change in scope of service.

(c) The request for a rate review must provide a detailed explanation and evidence to prove why a rate adjustment is warranted. The FQHC should demonstrate that by providing either:

(i) A community needs assessment shows that population demographic changes warrant the change in scope of service; or

(ii) A business plan or other similar documentation indicates that the new service is warranted; and

(iii) Efforts were made to address the problem outside of the rate review process.

(d) If the request is due to a change in the intensity of services provided, the FQHC must provide evidence that the intensity of services has changed and that the increased costs are directly related to the change in intensity of service. This evidence might include a report showing that patients' diagnoses have changed the acuity of care or a report proving that the relative values of the services provided has changed.

(e) The FQHC must file two complete cost reports as specified in rule 5101:3-28-10 of the Administrative Code that include all schedules and attachments specified for the JFS 03421 cost report and documentation supporting the cost increase. The FQHC must specify in its written request exactly what cost centers in the cost report have been impacted by the increased costs for the service that has changed in scope and why they were impacted. Failure to file the cost reports within the time period described in paragraph (A)(3) of rule 5101:3-28-10 of the Administrative Code will mean that the department will not evaluate the request for consideration of a change in scope.

(8) The department shall respond in writing within sixty days of receiving each written request for a change in scope of service. If the department requests additional information to determine if the rate request is warranted, the department shall respond in writing within sixty days of receiving the additional information.

(9) If a request for a rate adjustment due to a change in scope of service is granted, the following provisions will apply:

(a) The department will review the FQHC's costs for the service that has changed in scope and will set a rate based on the reasonable cost parameters described in paragraphs (B)(4) to (B)(7) of this rule.

(b) The rate increase shall be the difference between the new rate calculated for the service that has changed in scope minus the rate previously calculated for the prior year for that category of service. The rate increase amount shall be added to the current year's PPS rate for that specific category of service for the FQHC.

(c) The rate described in paragraph (C)(9)(b) of this rule shall be inflated by the MEI in accordance with paragraph (C) of rule 5101:3-28-08 of the Administrative Code.

(d) The rate adjustment shall be effective on the first day of the first full month after the department has granted the request. Retroactive adjustments will not be made.

(D) The department's decision at the conclusion of the rate review process shall not be subject to any administrative proceedings under Chapter 119. of the Revised Code.

(E) An FQHC must notify the department in writing within ninety days of any permanent decrease in a scope of service.

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

5160-28-10 Federally qualified health centers (FQHCs): prospective payment system cost report.

(A) If the following situations apply to an FQHC, thea JFS 03421 (rev. 07/2001) cost report(s) must be filed with the department:

(1) An entity is newly- qualified as an FQHC on or after July 1, 2001 as described in rule 5101:3-28-01 of the Administrative Code;

(2) An existing FQHC has added a service that has changed in scope because the FQHC began providing a new category of service as defined in paragraph (B) of rule 5101:3-28-09 of the Administrative Code; and

(3) An FQHC has requested that the department review a request for a change in scope of service as described in paragraph (C) of rule 5101:3-28-09 of the Administrative Code.

(B) Filing requirements

(1) If a cost report is required because the FQHC meets the condition described in paragraph (A)(1) of this rule, the cost report must be filed within ninety days after the close of one full year of operation of the new FQHC. The cost report shall be filed in accordance with the instructions specified for the JFS 03421 and must cover the period beginning the first day of the first full month after the new FQHC became qualified as an FQHC.

(2) If a cost report is required because the FQHC has added a new category of service as described in paragraph (A)(2) of this rule, the cost report shall be filed within ninety days after the close of one full year of operation of the new FQHC. The cost report shall be filed in accordance with the instructions specified for the JFS 03421 and shall cover the period beginning on the first day of the first full month after the new category of services was added.

(3) If cost reports are required because the FQHC meets the condition described in paragraph (A)(3) of this rule, two cost reports must be filed.

(a) The first cost report shall be filed in accordance with the instructions specified for the JFS 03421 and shall cover the twelve month period ending the last day of the last month before the service changed in scope and shall be submitted to the department, with all required documentation, within ninety days after the close of the twelve month period.

(b) The second cost report shall be filed in accordance with the instructions specified for the JFS 03421 and shall cover the twelve month period beginning on the first day of the first full month after the service that has changed in scope began operation and shall be submitted to the department with all required documentation within ninety days after the close of the twelve month period.

(C) Failure to file complete and accurate cost reports within the time frames established in paragraph (B) of this rule will result in the department making no adjustments to the rate(s) for a service that the FQHC claims has changed in scope of service. No extensions will be granted for cost report filings.

(D) The cost report form, JFS 03421, to be submitted by the FQHC shall be supplied by the department. The FQHC must request the cost report software from the department by contacting the manager of financial operations within the bureau of health plan policy in the office of medicaid.

(E) The FQHC must complete and return the cost report to the department within the time frames stated in paragraph (B) of this rule.

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

5160-28-11 Federally qualified health centers (FQHCs): billing for FQHC services.

(A) For services provided on or after October 1, 2003, FQHCs shall include the following data elements unique for FQHC billings:

(1) The code T1015;.

(2) The code to specify the type of encounter provided, e.g., T1015U1:

(a) For a medical encounter, use the modifier U1;

(b) For a dental encounter, use the modifier U2;

(c) For a mental health encounter, use the modifier U3;

(d) For a physical therapy encounter, use the modifier U4;

(e) For a speech therapypathology encounter, use the modifier U5;

(f) For a podiatry encounter, use the modifier U6;

(g) For an optometric and/or optician services encounter, use the modifier U7;

(h) For a chiropractic encounter, use the modifier U8; and

(i) For a transportation encounter, use the modifier U9.

(3) All procedure codes whichthat describe the services provided during the encounter.

(B) If the services is provided on or after October 1, 2003 and the claim is for a supplemental payment, follow the applicable instructions found in this rule addressing coding and modifiers. In addition, submit the unique data elements required for a supplemental payment found in rule 5101:3-28-07 of the Administrative Code.

(C) For consumers in the medicaid managed care program, claims submission requirements, including prior authorization requests for FQHC services as defined in Chapter 5101:3-28 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: 03/09/2006 and 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 10/1/03