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(1) This subchapter specifies requirements applicable to provision of and reimbursement for RHC and FQHC services. These rules are in addition to requirements generally applicable to Medicaid providers as otherwise provided in state and federal statute, rules, regulations, and policies.

(2) Unless otherwise provided in these rules, this subchapter applies to rate years beginning on or after January 1, 2001. Reimbursement and other substantive RHC and FQHC requirements for earlier periods are subject to the laws, regulations, rules, and policies then in effect. Procedural and other nonsubstantive provisions of these rules are effective upon adoption.

(3) All RHCs and FQHCs will be reimbursed on a prospective payment system (PPS) beginning January 1, 2001 and each succeeding calendar year. The PPS will apply equally to provider based and independent RHCs and FQHCs.

(4)  On January 1 of each succeeding calendar year, the rate for the preceding year must be adjusted by the percentage increase in the medicare economic index (MEI) applicable to primary care services for that calendar year.

(5)  The department will reimburse the RHC or FQHC for the rate change in (4) retroactive to the effective date of January 1 of the calendar year, beginning with January 1, 2002.

(6) For RHCs or FQHCs that had their initial Medicaid prospective payment system base visit rate calculated in 2001 or starting with the third fiscal year (for "new" RHCs or FQHCs as defined at ARM 37.86.4413), the prospective payment system per-visit rate may be adjusted to take into account any increase or decrease in the scope of service. The department uses the following calculations to determine the amount of an incremental change, if any, and the resulting new PPS rate:


                                                               A/B = C

                                                               D/E = F

                                                               F-C = IC


                                        Current PPS rate + IC = New PPS rate


(a) "A" represents allowable costs before the change in scope of service;

(b) "B" represents total visits before the change in scope of service;

(c) "C" represents cost per visit before the change in scope of service;

(d) "D" represents allowable costs after the change in scope of service;

(e) "E" represents total visits after the change in scope of service;

(f) "F" represents cost per visit after the change in scope of service; and

(g) "IC" represents the incremental change due to the change in scope of services.

(7) Effective July 1, 2017, approved RHCs and FQHCs participating in Promising Pregnancy Care (PPC) will be reimbursed an enhanced PPS rate. Therefore, RHCs and FQHCs will be reimbursed their existing PPS rate plus an additional amount, in accordance with the fee schedule adopted and effective as provided in ARM 37.85.105, whenever a member attends the educational aspect of the PPC session.

(8) Effective July 1, 2017, RHCs and FQHCs will be reimbursed separately for long-acting reversible contraceptives (LARCs) in addition to their PPS rate. LARCs include intrauterine devices (IUDs) and birth control implants.


History: 53-2-201, 53-6-113, MCA; IMP, 53-6-101, 53-6-111, 53-6-113, MCA; NEW, 1998 MAR p. 2045, Eff. 7/31/98; TRANS, from SRS, 2000 MAR p. 481; AMD, 2001 MAR p. 2043, Eff. 10/12/01; AMD, 2005 MAR p. 975, Eff. 6/17/05; AMD, 2016 MAR p. 1712, Eff. 10/1/16; AMD, 2017 MAR p. 2303, Eff. 12/9/17; AMD, 2019 MAR p. 1866, Eff. 10/19/19.

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