Administrative Rules of the State of Montana

37.86.4413 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, ESTABLISHMENT OF INITIAL PAYMENT FOR NEW CLINICS OR CENTERS

(1) To determine the initial medicaid prospective payment system base per visit rate for a newly qualified RHC or FQHC, reimbursement shall be equal to 100% of the average prospective payment system rates for other RHCs or FQHCs located in the same or adjacent area with a similar caseload. In the event that there is no such RHC or FQHC, payment shall be made in accordance with the methodology provided in (2) through (4).

(2) During the RHC's or FQHC's first two fiscal years, the RHC or FQHC will be reimbursed on a per visit basis equal to the RHC's or FQHC's total projected costs divided by the RHC's or FQHC's total projected visits. The provider must submit to the department or its agent an estimate of budgeted costs and visits for the RHC or FQHC for the reporting period in the form and detail required by the department and such other information as the department may require to establish a rate.

(3) At the end of the RHC's or FQHC's first two fiscal years, a new per visit rate shall be established that is equal to 100% of the allowable costs of the RHC or FQHC furnishing such services during the RHC's or FQHC's first two fiscal years which are reasonable and related to the cost of furnishing such services. The provider must submit to the department or its agent the costs and visits for the RHC or FQHC for the reporting period in the form and detail required by the department and such other information as the department may require to establish a rate.

(a) The formula for calculating this new base per visit rate is the total cost of core and other ambulatory services for the first two fiscal years divided by the total core and other ambulatory visits for the first two fiscal years. This base cost per visit rate may be adjusted to take into account any increase or decrease in the scope of service as provided in ARM 37.86.4412.

(b) The department shall reimburse the RHC or FQHC this new base rate retroactive to the effective date of their enrollment as an RHC or FQHC.

(4) Reimbursement for the third year forward shall be as in ARM 37.86.4406 and 37.86.4412.

History: Sec. 53-2-201 and 53-6-113, MCA; IMP, Sec. 53-2-201, 53-6-101, 53-6-111 and 53-6-113, MCA; NEW, 1998 MAR p. 2045, Eff. 7/31/98; TRANS, from SRS, 2000 MAR p. 481; AMD, 2001 MAR p. 1476, Eff. 8/10/01; AMD, 2001 MAR p. 2043, Eff. 10/12/01; AMD, 2001 MAR p. 2156, Eff. 10/26/01; AMD, 2005 MAR p. 1402, Eff. 6/17/05.