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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-28. Cost-Based Clinic (FQHC, OHF, RHC) Services |
5160-28-05.3. Cost-based clinics: prospective payment system (PPS) method for determining RHC payment
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This rule addresses how the department complies with provisions set forth in Section 702 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) that require states to establish a medicaid prospective payment system (PPS) for rural health clinic (RHC) services.
(A) An all-inclusive per-visit payment amount (PVPA) is established for an RHC service provided at an RHC service site.
(1) For every RHC service site already enrolled as a medicaid provider, the department establishes a new PVPA equal to the current PVPA adjusted by the percentage of the latest available medicare economic index (MEI). The new PVPA is established by October first of each year and is in effect from October first through the following September thirtieth.
(2) For an existing RHC that requests an adjustment based on a change in scope, the department may establish a new PVPA based on a cost report in accordance with rule 5160-28-04.3 of the Administrative Code.
(3) For an RHC that is enrolling as a new medicaid provider, the department establishes an initial PVPA in accordance with the following procedure:
(a) First, the initial PVPA is set equal to the PVPAs of other RHCs in the immediate area that are similar in size, caseload, and scope of services. If no such RHC exists, then the initial PVPA is set equal to the current PVPA at the statewide sixtieth percentile for RHCs. This initial PVPA remains in effect until a new PVPA is established.
(b) After the initial PVPA is set, the RHC submits a cost report in accordance with rule 5160-28-04.3 of the Administrative Code. A new PVPA is established on the basis of the cost report and is adjusted by any changes in the MEI that have occurred since the cost report was submitted.
(c) Thereafter, the PVPA is adjusted in accordance with paragraph (A)(1) of this rule.
(B) A PVPA based on a cost report is effective from the first day of the first full month after the department 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 adjusted by the appropriate MEI. No retroactive establishment or adjustment will be made for a PVPA.
(C) A PVPA is specific to an RHC service site. No RHC service site may submit claims based on the PVPA of another service site.
(D) Decisions of the department with respect to the establishment or adjustment of a PVPA are not subject to Chapter 119. of the Revised Code.