AB 1549: Medi-Cal: federally qualified health centers and rural health clinics.
- Session Year: 2023-2024
- House: Assembly
- Latest Version Date: 2023-04-27
Current Status:
Failed
(2024-02-01: From committee: Filed with the Chief Clerk pursuant to Joint Rule 56.)
Introduced
In Committee
First Chamber
In Committee
Second Chamber
Enacted
What does this bill do?
This bill changes how Medi‑Cal pays federally qualified health centers (FQHCs) and rural health clinics (RHCs) by requiring the per‑visit payment to reflect the center’s reasonable costs of providing care, including the staffing and care‑delivery models the center uses. It also requires that the per‑visit rate for any newly qualified health center include the cost of care coordination—work by care coordinators, nurses, social workers, or similar staff to organize services, arrange transportation, provide education, make referrals, and help patients follow care plans.
The summary is provided by generative AI which can make mistakes. For original language, please view the details in the table below.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including federally qualified health center services and rural health clinic services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.
Under existing law, to the extent that federal financial participation is available, FQHC and RHC services are reimbursed on a per-visit basis, as specified.
This bill would, among other things, require that per-visit rate to account for the costs of the FQHC or RHC that are reasonable and related to the provision of covered services, including the specific methods and processes staffing and care delivery models used by the FQHC and RHC to deliver those services. The bill would also require the rate for any newly qualified health center to include the cost of care coordination services provided by the health center, as specified.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including federally qualified health center services and rural health clinic services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.
This bill would make technical, nonsubstantive changes to these provisions.Under existing law, to the extent that federal financial participation is available, FQHC and RHC services are reimbursed on a per-visit basis, as specified.
This bill would, among other things, require that per-visit rate to account for the costs of the FQHC or RHC that are reasonable and related to the provision of covered services, including the specific methods and processes used by the FQHC and RHC to deliver those services. The bill would also require the rate for any newly qualified health center to include the cost of care coordination services provided by the health center, as specified.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including federally qualified health center services and rural health clinic services.
This bill would make technical, nonsubstantive changes to these provisions.
(a)The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.
(b)The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.
(c)(1)Federally qualified health center services and rural health clinic services shall be reimbursed on a per-visit basis in accordance with the definition of visit set forth in subdivision (g).
(2)The per-visit basis pursuant to paragraph (1) shall account for the costs of the FQHC or RHC that are reasonable and related to the provision of covered services identified in subdivisions (a) and (b), including the specific methods and processes staffing and care delivery models used by the FQHC and RHC to deliver those services.
(3)For purposes of this section, a change in the scope of services means a change in the type of covered services provided by an FQHC or RHC at a particular site or a change in methods or processes utilized by an FQHC or RHC to provide covered services that results in an increase or decrease in any of the following:(A)The intensity of activities taking place in an average visit that are reasonable and related to the provision of covered services.(B)The length or duration of an average visit.(C)The amount of activities provided by an FQHC or RHC in an average visit that are reasonable or related to the provision of covered services.(d)Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Before January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e)(1)An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC as described in subdivision (c). RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with the federal reasonable cost principles, as set forth in Subpart E (commencing with Section 75.400) of Part 75 of Title 45 of the Code of Federal Regulations.
(2)Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service includes, but is not limited to, any of the following:
(A)The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate, inclusive of those services described in paragraph (6) of subdivision (i). inclusive of, but not limited to, both of the following:
(i)Those services described in paragraph (6) of subdivision (i).
(ii)An addition or deletion of a service or a change in service based on services added to or deleted from the Medi-Cal state plan, whether or not the service is explicitly delineated in the state plan as an FQHC or RHC service.
(B)A change in service due to amended regulatory requirements or rules or a change related to a Medi-Cal managed care plan contracting under this chapter or Chapter 8 (commencing with Section 14200) that either directly or indirectly impacts an FQHC or RHC.
(C)A change in service resulting from relocating or remodeling an FQHC or RHC.
(D)A change in types of services due to a change in either of the following:
(i)Applicable technology, including upgrades, replacements, upgrades or replacements to existing technology utilized by the center or clinic.
(ii)Medical practice utilized by the center or clinic.
(E)A change in methods or processes utilized by an FQHC or RHC to provide covered services that results in an increase or decrease in any of the following:
(E)An(i)The intensity of activities taking place in an average visit that are reasonable and related to the provision of covered services, including any increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.
(ii)The length or duration of an average visit.
(iii)The amount of activities provided by an FQHC or RHC in an average visit that are reasonable or related to the provision of covered services.
(F)Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.
(G)Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (c), this subdivision, including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.
(H)Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.
(I)Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).
(J)The addition or deletion of care coordination services as described in paragraph (6) of subdivision (i).
(K)The addition or deletion of a service or a change in service necessary to comply with the Medi-Cal state plan.(3)A change in costs is not, in and of itself, a scope-of-service change, unless all of the following apply:
(A)The increase or decrease in cost is attributable to an increase or decrease in the scope of services described in subdivision (c).
(B)The cost is allowable pursuant to Subpart E (commencing with Section 75.400) of Part 75 of Title 45 of the Code of Federal Regulations without the application of cost caps or productivity screens. Federal guidance documents, unless specifically identified pursuant to this section, shall not be used by the department to determine the allowable costs of the FQHC or RHC. Regulations. Any federal guidance documents not specifically identified pursuant to this section, that are used to define allowable costs or otherwise describe the change in scope of services process shall be explicitly identified by the department through published guidance provided to FQHCs and RHCs.
(C)The net change in the FQHCs or RHCs rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. Net change means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4)(A)An adjustment to the FQHCs or RHCs per-visit rate based on an approved scope-of-service change shall account for 100 percent of the newly established cost per visit as determined from the cost report filed by the FQHC or RHC.
(B)For purposes of this section, newly established cost per visit shall mean the FQHCs or RHCs calculated cost per visit in effect on the first day of the fiscal year following the reporting period in which the scope-of-service change occurred.
(5)An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(6)An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHCs or RHCs prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, significantly lower means an average per-visit rate decrease in excess of 2.5 percent.
(7)Notwithstanding paragraph (5), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHCs or RHCs fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHCs or RHCs fiscal year ending in 2003.
(8)All references in this subdivision to fiscal year shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.
(f)(1)An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHCs or RHCs PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.
(2)The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.
(3)Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:
(A)A presentation of data to demonstrate reasons for the FQHCs or RHCs request for a supplemental payment.
(B)Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facilitys total costs, whichever is less.
(4)A request shall be submitted for each affected year.
(5)Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.
(6)The department shall notify the provider of the departments discretionary decision in writing.
(g)(1)An FQHC or RHC visit means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plans definition of an FQHC or RHC visit.
(2)(A)A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist.
(B)Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHCs or RHCs rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHCs or RHCs application for, or the departments approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist has been approved. Any approved increase or decrease in the providers rate shall be made within six months after the date of receipt of the departments rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.
(C)An FQHC or RHC that does not provide dental hygienist, dental hygienist in alternative practice, or marriage and family therapist services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).
(3)Notwithstanding any other provision of this section, no later than July 1, 2018, a visit shall include a marriage and family therapist.
(4)(A)(i)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter. An FQHC or RHC is not precluded from establishing a new patient relationship through video synchronous interaction. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.
(ii)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using audio-only synchronous interaction, when services delivered through that modality meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.
(iii)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using an asynchronous store and forward modality, when services delivered through that modality meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.
(iv)(I)An FQHC or RHC may not establish a new patient relationship using an audio-only synchronous interaction.
(II)Notwithstanding subclause (I), the department may provide for exceptions to the prohibition established by subclause (I), including, but not limited to, the exceptions described in sub-subclauses (ia) and (ib), which shall be developed in consultation with affected stakeholders and published in departmental guidance.
(ia)Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the visit is related to sensitive services, as defined in subdivision (n) of Section 56.05 of the Civil Code, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.
(ib)Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the patient requests an audio-only modality or attests they do not have access to video, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.
(v)An FQHC or RHC is not precluded from establishing a new patient relationship through an asynchronous store and forward modality, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, if the visit meets all of the following conditions:
(I)The patient is physically present at the FQHC or RHC, or at an intermittent site of the FQHC or RHC, at the time the service is performed.
(II)The individual who creates the patient records at the originating site is an employee or contractor of the FQHC or RHC, or other person lawfully authorized by the FQHC or RHC to create a patient record.
(III)The FQHC or RHC determines that the billing provider is able to meet the applicable standard of care.
(IV)An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.
(B)(i)Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary choice.
(ii)The department may provide specific exceptions to the requirement specified in clause (i), based on an FQHCs or RHCs access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance.
(iii)Effective on the date designated by the department pursuant to clause (i), an FQHC or RHC furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:
(I)Offer those services via in-person, face-to-face contact.
(II)Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.
(iv)In addition to any existing law requiring beneficiary consent to telehealth, including, but not limited to, subdivision (b) of Section 2290.5 of the Business and Professions Code, all of the following shall be communicated by an FQHC or RHC to a Medi-Cal beneficiary, in writing or verbally, on at least one occasion before, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal beneficiary: an explanation that beneficiaries have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit; an explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal beneficiary without affecting their ability to access covered Medi-Cal services in the future; an explanation of the availability of Medi-Cal coverage for nonmedical transportation services to in-person visits when other available resources have been reasonably exhausted; and the potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the FQHC or RHC.
(I)The FQHC or RHC shall document in the patient record the provision of this information and the patients verbal or written acknowledgment that the information was received.
(II)The department shall develop, in consultation with affected stakeholders, model language for purposes of the communication described in this subparagraph.
(C)The department shall seek any federal approvals it deems necessary to implement this paragraph. This paragraph shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and not otherwise jeopardized.
(D)This paragraph shall be operative on January 1, 2023, or on the operative date or dates reflected in the applicable federal approvals obtained by the department pursuant to subparagraph (C), whichever is later. This paragraph shall not be construed to limit coverage of, and reimbursement for, covered telehealth services provided before the operative date of this paragraph.
(E)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this paragraph by means of all-county letters, plan letters, provider manuals, information notices, provider bulletins, and similar instructions, without taking any further regulatory action.
(F)Telehealth modalities authorized pursuant to this paragraph shall be subject to the billing, reimbursement, and utilization management policies imposed by the department.
(G)Services delivered via telehealth modalities described in this paragraph shall comply with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, the Medicaid state plan, and any other applicable state and federal statutes and regulations.
(5)For purposes of this section, physician shall be interpreted in a manner consistent with the federal Centers for Medicare and Medicaid Services Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor.
(h)If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial or quality incentive payments.
(i)(1)Provided that the following entities are not operating as intermittent clinics, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, each entity shall have its reimbursement rate established in accordance with one of the methods outlined in paragraph (2) or (3), as selected by the FQHC or RHC:
(A)An entity that first qualifies as an FQHC or RHC in 2001 or later.
(B)A newly licensed facility at a new location added to an existing FQHC or RHC.
(C)An entity that is an existing FQHC or RHC that is relocated to a new site.
(2)(A)An FQHC or RHC that adds a new licensed location to its existing primary care license under paragraph (1) of subdivision (b) of Section 1212 of the Health and Safety Code may elect to have the reimbursement rate for the new location established in accordance with paragraph (3), or notwithstanding subdivision (e), an FQHC or RHC may choose to have one PPS rate for all locations that appear on its primary care license determined by submitting a change in scope of service request if both of the following requirements are met:
(i)The change in scope of service request includes the costs and visits for those locations for the first full fiscal year immediately following the date the new location is added to the FQHCs or RHCs existing licensee.
(ii)The FQHC or RHC submits the change in scope of service request within 90 days after the FQHCs or RHCs first full fiscal year.
(B)The FQHCs or RHCs single PPS rate for those locations shall be calculated based on the total costs and total visits of those locations and shall be determined based on the following:
(i)An audit in accordance with Section 14170.
(ii)Rate changes based on a change in scope of service request shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successors.
(iii)Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(C)Except as specified in subdivision (j), this paragraph does not apply to a location that was added to an existing primary care clinic license by the State Department of Public Health, whether by a regional district office or the centralized application unit, before January 1, 2017.
(3)If an FQHC or RHC does not elect to have the PPS rate determined by a change in scope of service request, the FQHC or RHC shall have the reimbursement rate established for any of the entities identified in paragraph (1) or (2) in accordance with one of the following methods at the election of the FQHC or RHC:
(A)The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.
(B)In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(C)At a new entitys one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.
(D)The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(4)In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.
(5)The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHCs or RHCs prospective payment rate at that time.
(6)(A)The rate for any newly qualified health center set under this subdivision shall include the cost of care coordination services provided by the health center.
(B)Care coordination services shall be provided by individuals trained as, and with specific titles titles, including, but not limited to, care coordinators, case managers, referral coordinators, or other titles titles, including, but not limited to, nurses, social workers, and other professional staff who are specifically allocated to care coordination during assigned hours, but not when these services are an integral part of their other duties including providing direct patient care.
(C)For purposes of this section, care coordination shall mean the deliberate organization of patient care activities and sharing information among all of the participants concerned with a patients care to achieve safer and more effective care. Care coordination includes, but is not limited to:
(i)Coordination of covered services.
(ii)Arranging for transportation to and from a source of medical care.
(iii)Patient education regarding covered services, the benefits of preventive medical and dental care, and how to efficiently utilize the health care system and access services.
(iv)Prenatal education or health education.
(v)Referral for services, community resources, or other agencies for needed services or items.
(vi)Assistance to ensure client compliance with services prescribed or recommended services, including, but not limited to, substance abuse treatment, early intervention services, behavioral health, and specialty care.
(vii)Facilitating communication among the patients health care providers, including, but not limited to, behavioral health and substance abuse providers when appropriate.
(j)(1)Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, in a mobile unit as defined by paragraph (2) of subdivision (b) of Section 1765.105 of the Health and Safety Code, or at the election of the FQHC or RHC and subject to paragraph (2), a location added to an existing primary care clinic license by the State Department of Public Health before January 1, 2017, shall be billed by and reimbursed at the same rate as the FQHC or RHC that either established the intermittent clinic site or mobile unit, or that held the clinic license to which the location was added before January 1, 2017.
(2)If an FQHC or RHC with at least one additional location on its primary care clinic license that was added by the State Department of Public Health before January 1, 2017, applies for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC as described in subdivision (e), all locations on the FQHCs or RHCs primary care clinic license shall be subject to a scope-of-service adjustment in accordance with either paragraph (2) or (3) of subdivision (i), as selected by the FQHC or RHC.
(3)This subdivision does not preclude or otherwise limit the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.
(k)An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).
(l)Reimbursement for Drug Medi-Cal services shall be provided pursuant to this subdivision.
(1)An FQHC or RHC may elect to have Drug Medi-Cal services reimbursed directly from a county or the department under contract with the FQHC or RHC pursuant to paragraph (4).
(2)(A)For an FQHC or RHC to receive reimbursement for Drug Medi-Cal services directly from the county or the department under contract with the FQHC or RHC pursuant to paragraph (4), costs associated with providing Drug Medi-Cal services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing Drug Medi-Cal services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering Drug Medi-Cal services the clinic uses different clinical staff at a different location.
(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver Drug Medi-Cal services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering Drug Medi-Cal services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.
(3)If the costs associated with providing Drug Medi-Cal services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the Drug Medi-Cal services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.
(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering Drug Medi-Cal services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include Drug Medi-Cal services costs.
(B)An FQHC or RHC may submit requests for scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department shall be retroactive to the first day that Drug Medi-Cal services were rendered and reimbursement for Drug Medi-Cal services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.
(C)The FQHC or RHC may bill for Drug Medi-Cal services outside of the PPS rate when the FQHC or RHC obtains approval as a Drug Medi-Cal provider and enters into a contract with a county or the department to provide these services pursuant to paragraph (4).
(D)Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F)For purposes of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and Drug Medi-Cal services.
(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate and the FQHC or RHC is approved as a Drug Medi-Cal provider, an FQHC or RHC shall not bill the PPS rate for any Drug Medi-Cal services provided pursuant to a contract entered into with a county or the department pursuant to paragraph (4).
(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4)Reimbursement for Drug Medi-Cal services shall be determined according to subparagraph (A) or (B), depending on whether the services are provided in a county that participates in the Drug Medi-Cal organized delivery system (DMC-ODS).
(A)In a county that participates in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county or county designee and the FQHC or RHC. If the county or county designee refuses to contract with the FQHC or RHC, the FQHC or RHC may follow the contract denial process set forth in the Special Terms and Conditions.
(B)In a county that does not participate in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county and the FQHC or RHC. If the county refuses to contract with the FQHC or RHC, the FQHC or RHC may request to contract directly with the department and shall be reimbursed for those services at the Drug Medi-Cal fee-for-service rate.
(5)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments for Drug Medi-Cal services made pursuant to this subdivision.
(6)For purposes of this subdivision, the following definitions apply:
(A)Drug Medi-Cal organized delivery system or DMC-ODS means the Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions.
(B)Special Terms and Conditions has the same meaning as set forth in subdivision (o) of Section 14184.10.
(m)Reimbursement for specialty mental health services shall be provided pursuant to this subdivision.
(1)An FQHC or RHC and one or more mental health plans that contract with the department pursuant to Section 14712 may mutually elect to enter into a contract to have the FQHC or RHC provide specialty mental health services to Medi-Cal beneficiaries as part of the mental health plans network.
(2)(A)For an FQHC or RHC to receive reimbursement for specialty mental health services pursuant to a contract entered into with the mental health plan under paragraph (1), the costs associated with providing specialty mental health services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing specialty mental health services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering specialty mental health services the clinic uses different clinical staff at a different location.
(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver specialty mental health services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering specialty mental health services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.
(3)If the costs associated with providing specialty mental health services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the specialty mental health services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.
(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering specialty mental health services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include specialty mental health costs.
(B)An FQHC or RHC may submit requests for a scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department is retroactive to the first day that specialty mental health services were rendered and reimbursement for specialty mental health services was received outside of the PPS rate, but the effective date shall not be earlier than January 1, 2018.
(C)The FQHC or RHC may bill for specialty mental health services outside of the PPS rate when the FQHC or RHC contracts with a mental health plan to provide these services pursuant to paragraph (1).
(D)Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F)For the purpose of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and specialty mental health services.
(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate, an FQHC or RHC shall not bill the PPS rate for any specialty mental health services that are provided pursuant to a contract entered into with a mental health plan pursuant to paragraph (1).
(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments made for specialty mental health services under this subdivision.
(n)The department shall seek any necessary federal approvals and issue appropriate guidance to allow an FQHC or RHC to bill, under a supervising licensed behavioral health practitioner, for an encounter between an FQHC or RHC patient and an associate clinical social worker or associate marriage and family therapist when all of the following conditions are met:
(1)The associate clinical social worker or the associate marriage and family therapist is supervised by the licensed behavioral health practitioner, as required by the Board of Behavioral Sciences.
(2)The visit is billed under the supervising licensed behavioral health practitioner of the FQHC or RHC.
(3)The FQHC or RHC is otherwise authorized to bill for services provided by the supervising licensed behavioral health practitioner as a separate visit.
(o)FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(p)The department shall promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.
(q)The department shall implement this section only to the extent that federal financial participation is available.
(r)Notwithstanding any other law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific subdivisions (l) and (m) by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific the provisions of subdivisions (l) and (m), including all of the following:
(1)Notifying provider representatives in writing of the proposed action or change. The notice shall occur, and the applicable draft provider bulletin or similar instruction, shall be made available at least 10 business days before the meeting described in paragraph (2).
(2)Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the proposed action or change.
(3)Allowing for written input regarding the proposed action or change, to which the department shall provide summary written responses in conjunction with the issuance of the applicable final written provider bulletin or similar instruction.
(4)Providing at least 60 days advance notice of the effective date of the proposed action or change.
(a)The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.
(b)The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.
(c)(1)Federally qualified health center services and rural health clinic services shall be reimbursed on a per-visit basis in accordance with the definition of visit set forth in subdivision (g).
(2)The per-visit basis pursuant to paragraph (1) shall account for the costs of the FQHC or RHC that are reasonable and related to the provision of covered services identified in subdivisions (a) and (b), including the specific methods and processes used by the FQHC and RHC to deliver those services.
(3)For purposes of this section, a change in the scope of services means a change in the type of covered services provided by an FQHC or RHC at a particular site or a change in methods or processes utilized by an FQHC or RHC to provide covered services that results in an increase or decrease in any of the following:
(A)The intensity of activities taking place in an average visit that are reasonable and related to the provision of covered services.
(B)The length or duration of an average visit.
(C)The amount of activities provided by an FQHC or RHC in an average visit that are reasonable or related to the provision of covered services.
(d)Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Before January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e)(1)An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. RHC as described in subdivision (c). Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare the federal reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor. Subpart E (commencing with Section 75.400) of Part 75 of Title 45 of the Code of Federal Regulations.
(2)Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means includes, but is not limited to, any of the following:
(A)The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate. rate, inclusive of those services described in paragraph (6) of subdivision (i).
(B)A change in service due to amended regulatory requirements or rules. rules or a change related to a Medi-Cal managed care plan contracting under this chapter or Chapter 8 (commencing with Section 14200) that either directly or indirectly impacts an FQHC or RHC.
(C)A change in service resulting from relocating or remodeling an FQHC or RHC.
(D)A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic. either of the following:
(i)Applicable technology, including upgrades, replacements, or replacements to existing technology utilized by the center or clinic.
(ii)Medical practice utilized by the center or clinic.
(E)An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.
(F)Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.
(G)Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), (c), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.
(H)Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.
(I)Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).
(J)The addition or deletion of care coordination services as described in paragraph (6) of subdivision (i).
(K)The addition or deletion of a service or a change in service necessary to comply with the Medi-Cal state plan.
(3)A change in costs is not, in and of itself, a scope-of-service change, unless all of the following apply:
(A)The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable. described in subdivision (c).
(B)The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413) of Subchapter B of Chapter 4 of Title 42 of the Code of Federal Regulations, or its successor. pursuant to Subpart E (commencing with Section 75.400) of Part 75 of Title 45 of the Code of Federal Regulations without the application of cost caps or productivity screens. Federal guidance documents, unless specifically identified pursuant to this section, shall not be used by the department to determine the allowable costs of the FQHC or RHC.
(C)The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination thereof.(D)(C)The net change in the FQHCs or RHCs rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. Net change means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4)(A)An adjustment to the FQHCs or RHCs per-visit rate based on an approved scope-of-service change shall account for 100 percent of the newly established cost per visit as determined from the cost report filed by the FQHC or RHC.
(B)For purposes of this section, newly established cost per visit shall mean the FQHCs or RHCs calculated cost per visit in effect on the first day of the fiscal year following the reporting period in which the scope-of-service change occurred.
(4)(5)An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(5)(6)An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHCs or RHCs prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, significantly lower means an average per-visit rate decrease in excess of 2.5 percent.
(6)(7)Notwithstanding paragraph (4), (5), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHCs or RHCs fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHCs or RHCs fiscal year ending in 2003.
(7)(8)All references in this subdivision to fiscal year shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.
(f)(1)An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHCs or RHCs PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.
(2)The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.
(3)Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:
(A)A presentation of data to demonstrate reasons for the FQHCs or RHCs request for a supplemental payment.
(B)Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facilitys total costs, whichever is less.
(4)A request shall be submitted for each affected year.
(5)Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.
(6)The department shall notify the provider of the departments discretionary decision in writing.
(g)(1)An FQHC or RHC visit means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plans definition of an FQHC or RHC visit.
(2)(A)A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist.
(B)Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHCs or RHCs rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHCs or RHCs application for, or the departments approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist has been approved. Any approved increase or decrease in the providers rate shall be made within six months after the date of receipt of the departments rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.
(C)An FQHC or RHC that does not provide dental hygienist, dental hygienist in alternative practice, or marriage and family therapist services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).
(3)Notwithstanding any other provision of this section, no later than July 1, 2018, a visit shall include a marriage and family therapist.
(4)(A)(i)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter. An FQHC or RHC is not precluded from establishing a new patient relationship through video synchronous interaction. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.
(ii)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using audio-only synchronous interaction, when services delivered through that modality meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.
(iii)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using an asynchronous store and forward modality, when services delivered through that modality meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.
(iv)(I)An FQHC or RHC may not establish a new patient relationship using an audio-only synchronous interaction.
(II)Notwithstanding subclause (I), the department may provide for exceptions to the prohibition established by subclause (I), including, but not limited to, the exceptions described in sub-subclauses (ia) and (ib), which shall be developed in consultation with affected stakeholders and published in departmental guidance.
(ia)Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the visit is related to sensitive services, as defined in subdivision (n) of Section 56.05 of the Civil Code, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.
(ib)Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the patient requests an audio-only modality or attests they do not have access to video, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.
(v)An FQHC or RHC is not precluded from establishing a new patient relationship through an asynchronous store and forward modality, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, if the visit meets all of the following conditions:
(I)The patient is physically present at the FQHC or RHC, or at an intermittent site of the FQHC or RHC, at the time the service is performed.
(II)The individual who creates the patient records at the originating site is an employee or contractor of the FQHC or RHC, or other person lawfully authorized by the FQHC or RHC to create a patient record.
(III)The FQHC or RHC determines that the billing provider is able to meet the applicable standard of care.
(IV)An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.
(B)(i)Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary choice.
(ii)The department may provide specific exceptions to the requirement specified in clause (i), based on an FQHCs or RHCs access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance.
(iii)Effective on the date designated by the department pursuant to clause (i), an FQHC or RHC furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:
(I)Offer those services via in-person, face-to-face contact.
(II)Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.
(iv)In addition to any existing law requiring beneficiary consent to telehealth, including, but not limited to, subdivision (b) of Section 2290.5 of the Business and Professions Code, all of the following shall be communicated by an FQHC or RHC to a Medi-Cal beneficiary, in writing or verbally, on at least one occasion before, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal beneficiary: an explanation that beneficiaries have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit; an explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal beneficiary without affecting their ability to access covered Medi-Cal services in the future; an explanation of the availability of Medi-Cal coverage for nonmedical transportation services to in-person visits when other available resources have been reasonably exhausted; and the potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the FQHC or RHC.
(I)The FQHC or RHC shall document in the patient record the provision of this information and the patients verbal or written acknowledgment that the information was received.
(II)The department shall develop, in consultation with affected stakeholders, model language for purposes of the communication described in this subparagraph.
(C)The department shall seek any federal approvals it deems necessary to implement this paragraph. This paragraph shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and not otherwise jeopardized.
(D)This paragraph shall be operative on January 1, 2023, or on the operative date or dates reflected in the applicable federal approvals obtained by the department pursuant to subparagraph (C), whichever is later. This paragraph shall not be construed to limit coverage of, and reimbursement for, covered telehealth services provided before the operative date of this paragraph.
(E)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this paragraph by means of all-county letters, plan letters, provider manuals, information notices, provider bulletins, and similar instructions, without taking any further regulatory action.
(F)Telehealth modalities authorized pursuant to this paragraph shall be subject to the billing, reimbursement, and utilization management policies imposed by the department.
(G)Services delivered via telehealth modalities described in this paragraph shall comply with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, the Medicaid state plan, and any other applicable state and federal statutes and regulations.
(5)For purposes of this section, physician shall be interpreted in a manner consistent with the federal Centers for Medicare and Medicaid Services Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor.
(h)If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation. or quality incentive payments.
(i)(1)Provided that the following entities are not operating as intermittent clinics, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, each entity shall have its reimbursement rate established in accordance with one of the methods outlined in paragraph (2) or (3), as selected by the FQHC or RHC:
(A)An entity that first qualifies as an FQHC or RHC in 2001 or later.
(B)A newly licensed facility at a new location added to an existing FQHC or RHC.
(C)An entity that is an existing FQHC or RHC that is relocated to a new site.
(2)(A)An FQHC or RHC that adds a new licensed location to its existing primary care license under paragraph (1) of subdivision (b) of Section 1212 of the Health and Safety Code may elect to have the reimbursement rate for the new location established in accordance with paragraph (3), or notwithstanding subdivision (e), an FQHC or RHC may choose to have one PPS rate for all locations that appear on its primary care license determined by submitting a change in scope of service request if both of the following requirements are met:
(i)The change in scope of service request includes the costs and visits for those locations for the first full fiscal year immediately following the date the new location is added to the FQHCs or RHCs existing licensee.
(ii)The FQHC or RHC submits the change in scope of service request within 90 days after the FQHCs or RHCs first full fiscal year.
(B)The FQHCs or RHCs single PPS rate for those locations shall be calculated based on the total costs and total visits of those locations and shall be determined based on the following:
(i)An audit in accordance with Section 14170.
(ii)Rate changes based on a change in scope of service request shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successors.
(iii)Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(C)Except as specified in subdivision (j), this paragraph does not apply to a location that was added to an existing primary care clinic license by the State Department of Public Health, whether by a regional district office or the centralized application unit, before January 1, 2017.
(3)If an FQHC or RHC does not elect to have the PPS rate determined by a change in scope of service request, the FQHC or RHC shall have the reimbursement rate established for any of the entities identified in paragraph (1) or (2) in accordance with one of the following methods at the election of the FQHC or RHC:
(A)The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.
(B)In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(C)At a new entitys one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.
(D)The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(4)In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.
(5)The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHCs or RHCs prospective payment rate at that time.
(6)(A)The rate for any newly qualified health center set under this subdivision shall include the cost of care coordination services provided by the health center.
(B)Care coordination services shall be provided by individuals trained as, and with specific titles including, but not limited to, care coordinators, case managers, referral coordinators, or other titles including, but not limited to, nurses, social workers, and other professional staff who are specifically allocated to care coordination during assigned hours, but not when these services are an integral part of their other duties including providing direct patient care.
(C)For purposes of this section, care coordination shall mean the deliberate organization of patient care activities and sharing information among all of the participants concerned with a patients care to achieve safer and more effective care. Care coordination includes, but is not limited to:
(i)Coordination of covered services.
(ii)Arranging for transportation to and from a source of medical care.
(iii)Patient education regarding covered services, the benefits of preventive medical and dental care, and how to efficiently utilize the health care system and access services.
(iv)Prenatal education or health education.
(v)Referral for services, community resources, or other agencies for needed services or items.
(vi)Assistance to ensure client compliance with services prescribed or recommended services, including, but not limited to, substance abuse treatment, early intervention services, behavioral health, and specialty care.
(vii)Facilitating communication among the patients health care providers, including, but not limited to, behavioral health and substance abuse providers when appropriate.
(j)(1)Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, in a mobile unit as defined by paragraph (2) of subdivision (b) of Section 1765.105 of the Health and Safety Code, or at the election of the FQHC or RHC and subject to paragraph (2), a location added to an existing primary care clinic license by the State Department of Public Health before January 1, 2017, shall be billed by and reimbursed at the same rate as the FQHC or RHC that either established the intermittent clinic site or mobile unit, or that held the clinic license to which the location was added before January 1, 2017.
(2)If an FQHC or RHC with at least one additional location on its primary care clinic license that was added by the State Department of Public Health before January 1, 2017, applies for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC as described in subdivision (e), all locations on the FQHCs or RHCs primary care clinic license shall be subject to a scope-of-service adjustment in accordance with either paragraph (2) or (3) of subdivision (i), as selected by the FQHC or RHC.
(3)This subdivision does not preclude or otherwise limit the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.
(k)An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).
(l)Reimbursement for Drug Medi-Cal services shall be provided pursuant to this subdivision.
(1)An FQHC or RHC may elect to have Drug Medi-Cal services reimbursed directly from a county or the department under contract with the FQHC or RHC pursuant to paragraph (4).
(2)(A)For an FQHC or RHC to receive reimbursement for Drug Medi-Cal services directly from the county or the department under contract with the FQHC or RHC pursuant to paragraph (4), costs associated with providing Drug Medi-Cal services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing Drug Medi-Cal services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering Drug Medi-Cal services the clinic uses different clinical staff at a different location.
(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver Drug Medi-Cal services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering Drug Medi-Cal services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.
(3)If the costs associated with providing Drug Medi-Cal services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the Drug Medi-Cal services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.
(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering Drug Medi-Cal services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include Drug Medi-Cal services costs.
(B)An FQHC or RHC may submit requests for scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department shall be retroactive to the first day that Drug Medi-Cal services were rendered and reimbursement for Drug Medi-Cal services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.
(C)The FQHC or RHC may bill for Drug Medi-Cal services outside of the PPS rate when the FQHC or RHC obtains approval as a Drug Medi-Cal provider and enters into a contract with a county or the department to provide these services pursuant to paragraph (4).
(D)Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F)For purposes of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and Drug Medi-Cal services.
(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate and the FQHC or RHC is approved as a Drug Medi-Cal provider, an FQHC or RHC shall not bill the PPS rate for any Drug Medi-Cal services provided pursuant to a contract entered into with a county or the department pursuant to paragraph (4).
(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4)Reimbursement for Drug Medi-Cal services shall be determined according to subparagraph (A) or (B), depending on whether the services are provided in a county that participates in the Drug Medi-Cal organized delivery system (DMC-ODS).
(A)In a county that participates in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county or county designee and the FQHC or RHC. If the county or county designee refuses to contract with the FQHC or RHC, the FQHC or RHC may follow the contract denial process set forth in the Special Terms and Conditions.
(B)In a county that does not participate in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county and the FQHC or RHC. If the county refuses to contract with the FQHC or RHC, the FQHC or RHC may request to contract directly with the department and shall be reimbursed for those services at the Drug Medi-Cal fee-for-service rate.
(5)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments for Drug Medi-Cal services made pursuant to this subdivision.
(6)For purposes of this subdivision, the following definitions apply:
(A)Drug Medi-Cal organized delivery system or DMC-ODS means the Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions.
(B)Special Terms and Conditions has the same meaning as set forth in subdivision (o) of Section 14184.10.
(m)Reimbursement for specialty mental health services shall be provided pursuant to this subdivision.
(1)An FQHC or RHC and one or more mental health plans that contract with the department pursuant to Section 14712 may mutually elect to enter into a contract to have the FQHC or RHC provide specialty mental health services to Medi-Cal beneficiaries as part of the mental health plans network.
(2)(A)For an FQHC or RHC to receive reimbursement for specialty mental health services pursuant to a contract entered into with the mental health plan under paragraph (1), the costs associated with providing specialty mental health services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing specialty mental health services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering specialty mental health services the clinic uses different clinical staff at a different location.
(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver specialty mental health services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering specialty mental health services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.
(3)If the costs associated with providing specialty mental health services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the specialty mental health services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.
(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering specialty mental health services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include specialty mental health costs.
(B)An FQHC or RHC may submit requests for a scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department is retroactive to the first day that specialty mental health services were rendered and reimbursement for specialty mental health services was received outside of the PPS rate, but the effective date shall not be earlier than January 1, 2018.
(C)The FQHC or RHC may bill for specialty mental health services outside of the PPS rate when the FQHC or RHC contracts with a mental health plan to provide these services pursuant to paragraph (1).
(D)Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F)For the purpose of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and specialty mental health services.
(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate, an FQHC or RHC shall not bill the PPS rate for any specialty mental health services that are provided pursuant to a contract entered into with a mental health plan pursuant to paragraph (1).
(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments made for specialty mental health services under this subdivision.
(n)The department shall seek any necessary federal approvals and issue appropriate guidance to allow an FQHC or RHC to bill, under a supervising licensed behavioral health practitioner, for an encounter between an FQHC or RHC patient and an associate clinical social worker or associate marriage and family therapist when all of the following conditions are met:
(1)The associate clinical social worker or the associate marriage and family therapist is supervised by the licensed behavioral health practitioner, as required by the Board of Behavioral Sciences.
(2)The visit is billed under the supervising licensed behavioral health practitioner of the FQHC or RHC.
(3)The FQHC or RHC is otherwise authorized to bill for services provided by the supervising licensed behavioral health practitioner as a separate visit.
(o)FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(p)The department shall promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.
(q)The department shall implement this section only to the extent that federal financial participation is available.
(r)Notwithstanding any other law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific subdivisions (l) and (m) by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific the provisions of subdivisions (l) and (m), including all of the following:
(1)Notifying provider representatives in writing of the proposed action or change. The notice shall occur, and the applicable draft provider bulletin or similar instruction, shall be made available at least 10 business days before the meeting described in paragraph (2).
(2)Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the proposed action or change.
(3)Allowing for written input regarding the proposed action or change, to which the department shall provide summary written responses in conjunction with the issuance of the applicable final written provider bulletin or similar instruction.
(4)Providing at least 60 days advance notice of the effective date of the proposed action or change.
(a)The federally qualified health center services described in Section 1396d(a)(2)(C) of Title 42 of the United States Code are covered benefits.
(b)The rural health clinic services described in Section 1396d(a)(2)(B) of Title 42 of the United States Code are covered benefits.
(c)Federally qualified health center services and rural health clinic services shall be reimbursed on a per-visit basis in accordance with the definition of visit set forth in subdivision (g).
(d)Effective October 1, 2004, and on each October 1 thereafter, until no longer required by federal law, federally qualified health center (FQHC) and rural health clinic (RHC) per-visit rates shall be increased by the Medicare Economic Index applicable to primary care services in the manner provided for in Section 1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to Before January 1, 2004, FQHC and RHC per-visit rates shall be adjusted by the Medicare Economic Index in accordance with the methodology set forth in the state plan in effect on October 1, 2001.
(e)(1)An FQHC or RHC may apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC. Rate changes based on a change in the scope of services provided by an FQHC or RHC shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(2)Subject to the conditions set forth in subparagraphs (A) to (D), inclusive, of paragraph (3), a change in scope of service means any of the following:
(A)The addition of a new FQHC or RHC service that is not incorporated in the baseline prospective payment system (PPS) rate, or a deletion of an FQHC or RHC service that is incorporated in the baseline PPS rate.
(B)A change in service due to amended regulatory requirements or rules.
(C)A change in service resulting from relocating or remodeling an FQHC or RHC.
(D)A change in types of services due to a change in applicable technology and medical practice utilized by the center or clinic.
(E)An increase in service intensity attributable to changes in the types of patients served, including, but not limited to, populations with HIV or AIDS, or other chronic diseases, or homeless, elderly, migrant, or other special populations.
(F)Any changes in any of the services described in subdivision (a) or (b), or in the provider mix of an FQHC or RHC or one of its sites.
(G)Changes in operating costs attributable to capital expenditures associated with a modification of the scope of any of the services described in subdivision (a) or (b), including new or expanded service facilities, regulatory compliance, or changes in technology or medical practices at the center or clinic.
(H)Indirect medical education adjustments and a direct graduate medical education payment that reflects the costs of providing teaching services to interns and residents.
(I)Any changes in the scope of a project approved by the federal Health Resources and Services Administration (HRSA).
(3)A change in costs is not, in and of itself, a scope-of-service change, unless all of the following apply:
(A)The increase or decrease in cost is attributable to an increase or decrease in the scope of services defined in subdivisions (a) and (b), as applicable.
(B)The cost is allowable under Medicare reasonable cost principles set forth in Part 413 (commencing with Section 413) of Subchapter B of Chapter 4 of Title 42 of the Code of Federal Regulations, or its successor.
(C)The change in the scope of services is a change in the type, intensity, duration, or amount of services, or any combination thereof.
(D)The net change in the FQHCs or RHCs rate equals or exceeds 1.75 percent for the affected FQHC or RHC site. For FQHCs and RHCs that filed consolidated cost reports for multiple sites to establish the initial prospective payment reimbursement rate, the 1.75-percent threshold shall be applied to the average per-visit rate of all sites for the purposes of calculating the cost associated with a scope-of-service change. Net change means the per-visit rate change attributable to the cumulative effect of all increases and decreases for a particular fiscal year.
(4)An FQHC or RHC may submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(5)An FQHC or RHC shall submit a scope-of-service rate change request within 90 days of the beginning of any FQHC or RHC fiscal year occurring after the effective date of this section, if, during the FQHCs or RHCs prior fiscal year, the FQHC or RHC experienced a decrease in the scope of services provided that the FQHC or RHC either knew or should have known would have resulted in a significantly lower per-visit rate. If an FQHC or RHC discontinues providing onsite pharmacy or dental services, it shall submit a scope-of-service rate change request within 90 days of the beginning of the following fiscal year. The rate change shall be effective as provided for in paragraph (4). As used in this paragraph, significantly lower means an average per-visit rate decrease in excess of 2.5 percent.
(6)Notwithstanding paragraph (4), if the approved scope-of-service change or changes were initially implemented on or after the first day of an FQHCs or RHCs fiscal year ending in calendar year 2001, but before the adoption and issuance of written instructions for applying for a scope-of-service change, the adjusted reimbursement rate for that scope-of-service change shall be made retroactive to the date the scope-of-service change was initially implemented. Scope-of-service changes under this paragraph shall be required to be submitted within the later of 150 days after the adoption and issuance of the written instructions by the department, or 150 days after the end of the FQHCs or RHCs fiscal year ending in 2003.
(7)All references in this subdivision to fiscal year shall be construed to be references to the fiscal year of the individual FQHC or RHC, as the case may be.
(f)(1)An FQHC or RHC may request a supplemental payment if extraordinary circumstances beyond the control of the FQHC or RHC occur after December 31, 2001, and PPS payments are insufficient due to these extraordinary circumstances. Supplemental payments arising from extraordinary circumstances under this subdivision shall be solely and exclusively within the discretion of the department and shall not be subject to subdivision (l). These supplemental payments shall be determined separately from the scope-of-service adjustments described in subdivision (e). Extraordinary circumstances include, but are not limited to, acts of nature, changes in applicable requirements in the Health and Safety Code, changes in applicable licensure requirements, and changes in applicable rules or regulations. Mere inflation of costs alone, absent extraordinary circumstances, shall not be grounds for supplemental payment. If an FQHCs or RHCs PPS rate is sufficient to cover its overall costs, including those associated with the extraordinary circumstances, then a supplemental payment is not warranted.
(2)The department shall accept requests for supplemental payment at any time throughout the prospective payment rate year.
(3)Requests for supplemental payments shall be submitted in writing to the department and shall set forth the reasons for the request. Each request shall be accompanied by sufficient documentation to enable the department to act upon the request. Documentation shall include the data necessary to demonstrate that the circumstances for which supplemental payment is requested meet the requirements set forth in this section. Documentation shall include both of the following:
(A)A presentation of data to demonstrate reasons for the FQHCs or RHCs request for a supplemental payment.
(B)Documentation showing the cost implications. The cost impact shall be material and significant, two hundred thousand dollars ($200,000) or 1 percent of a facilitys total costs, whichever is less.
(4)A request shall be submitted for each affected year.
(5)Amounts granted for supplemental payment requests shall be paid as lump-sum amounts for those years and not as revised PPS rates, and shall be repaid by the FQHC or RHC to the extent that it is not expended for the specified purposes.
(6)The department shall notify the provider of the departments discretionary decision in writing.
(g)(1)An FQHC or RHC visit means a face-to-face encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plans definition of an FQHC or RHC visit.
(2)(A)A visit shall also include a face-to-face encounter between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist.
(B)Notwithstanding subdivision (e), if an FQHC or RHC that currently includes the cost of the services of a dental hygienist in alternative practice, or a marriage and family therapist for the purposes of establishing its FQHC or RHC rate chooses to bill these services as a separate visit, the FQHC or RHC shall apply for an adjustment to its per-visit rate, and, after the rate adjustment has been approved by the department, shall bill these services as a separate visit. However, multiple encounters with dental professionals or marriage and family therapists that take place on the same day shall constitute a single visit. The department shall develop the appropriate forms to determine which FQHCs or RHCs rates shall be adjusted and to facilitate the calculation of the adjusted rates. An FQHCs or RHCs application for, or the departments approval of, a rate adjustment pursuant to this subparagraph shall not constitute a change in scope of service within the meaning of subdivision (e). An FQHC or RHC that applies for an adjustment to its rate pursuant to this subparagraph may continue to bill for all other FQHC or RHC visits at its existing per-visit rate, subject to reconciliation, until the rate adjustment for visits between an FQHC or RHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist has been approved. Any approved increase or decrease in the providers rate shall be made within six months after the date of receipt of the departments rate adjustment forms pursuant to this subparagraph and shall be retroactive to the beginning of the fiscal year in which the FQHC or RHC submits the request, but in no case shall the effective date be earlier than January 1, 2008.
(C)An FQHC or RHC that does not provide dental hygienist, dental hygienist in alternative practice, or marriage and family therapist services, and later elects to add these services and bill these services as a separate visit, shall process the addition of these services as a change in scope of service pursuant to subdivision (e).
(3)Notwithstanding any other provision of this section, no later than July 1, 2018, a visit shall include a marriage and family therapist.
(4)(A)(i)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter. An FQHC or RHC is not precluded from establishing a new patient relationship through video synchronous interaction. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.
(ii)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using audio-only synchronous interaction, when services delivered through that modality meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.
(iii)Subject to subparagraphs (C) and (D), a visit shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using an asynchronous store and forward modality, when services delivered through that modality meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHCs or RHCs per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.
(iv)(I)An FQHC or RHC may not establish a new patient relationship using an audio-only synchronous interaction.
(II)Notwithstanding subclause (I), the department may provide for exceptions to the prohibition established by subclause (I), including, but not limited to, the exceptions described in sub-subclauses (ia) and (ib), which shall be developed in consultation with affected stakeholders and published in departmental guidance.
(ia)Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the visit is related to sensitive services, as defined in subdivision (n) of Section 56.05 of the Civil Code, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.
(ib)Notwithstanding the prohibition in subclause (I) and subject to subparagraphs (C) and (D), an FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the patient requests an audio-only modality or attests they do not have access to video, and when established in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.
(v)An FQHC or RHC is not precluded from establishing a new patient relationship through an asynchronous store and forward modality, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, if the visit meets all of the following conditions:
(I)The patient is physically present at the FQHC or RHC, or at an intermittent site of the FQHC or RHC, at the time the service is performed.
(II)The individual who creates the patient records at the originating site is an employee or contractor of the FQHC or RHC, or other person lawfully authorized by the FQHC or RHC to create a patient record.
(III)The FQHC or RHC determines that the billing provider is able to meet the applicable standard of care.
(IV)An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.
(B)(i)Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary choice.
(ii)The department may provide specific exceptions to the requirement specified in clause (i), based on an FQHCs or RHCs access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance.
(iii)Effective on the date designated by the department pursuant to clause (i), an FQHC or RHC furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:
(I)Offer those services via in-person, face-to-face contact.
(II)Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.
(iv)In addition to any existing law requiring beneficiary consent to telehealth, including, but not limited to, subdivision (b) of Section 2290.5 of the Business and Professions Code, all of the following shall be communicated by an FQHC or RHC to a Medi-Cal beneficiary, in writing or verbally, on at least one occasion prior to, before, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal beneficiary: an explanation that beneficiaries have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit; an explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal beneficiary without affecting their ability to access covered Medi-Cal services in the future; an explanation of the availability of Medi-Cal coverage for nonmedical transportation services to in-person visits when other available resources have been reasonably exhausted; and the potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the FQHC or RHC.
(I)The FQHC or RHC shall document in the patient record the provision of this information and the patients verbal or written acknowledgment that the information was received.
(II)The department shall develop, in consultation with affected stakeholders, model language for purposes of the communication described in this subparagraph.
(C)The department shall seek any federal approvals it deems necessary to implement this paragraph. This paragraph shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available and not otherwise jeopardized.
(D)This paragraph shall be operative on January 1, 2023, or on the operative date or dates reflected in the applicable federal approvals obtained by the department pursuant to subparagraph (C), whichever is later. This paragraph shall not be construed to limit coverage of, and reimbursement for, covered telehealth services provided before the operative date of this paragraph.
(E)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this paragraph by means of all-county letters, plan letters, provider manuals, information notices, provider bulletins, and similar instructions, without taking any further regulatory action.
(F)Telehealth modalities authorized pursuant to this paragraph shall be subject to the billing, reimbursement, and utilization management policies imposed by the department.
(G)Services delivered via telehealth modalities described in this paragraph shall comply with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, the Medicaid state plan, and any other applicable state and federal statutes and regulations.
(5)For purposes of this section, physician shall be interpreted in a manner consistent with the federal Centers for Medicare and Medicaid Services Medicare Rural Health Clinic and Federally Qualified Health Center Manual (Publication 27), or its successor, only to the extent that it defines the professionals whose services are reimbursable on a per-visit basis and not as to the types of services that these professionals may render during these visits and shall include a physician and surgeon, osteopath, podiatrist, dentist, optometrist, and chiropractor.
(h)If FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity, as defined in Section 1396u-2(a)(1)(B) of Title 42 of the United States Code, the Medicare Program, or the Child Health and Disability Prevention (CHDP) Program, the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract-by-contract basis and not in the aggregate, and may not include managed care financial incentive payments that are required by federal law to be excluded from the calculation.
(i)(1)Provided that the following entities are not operating as intermittent clinics, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, each entity shall have its reimbursement rate established in accordance with one of the methods outlined in paragraph (2) or (3), as selected by the FQHC or RHC:
(A)An entity that first qualifies as an FQHC or RHC in 2001 or later.
(B)A newly licensed facility at a new location added to an existing FQHC or RHC.
(C)An entity that is an existing FQHC or RHC that is relocated to a new site.
(2)(A)An FQHC or RHC that adds a new licensed location to its existing primary care license under paragraph (1) of subdivision (b) of Section 1212 of the Health and Safety Code may elect to have the reimbursement rate for the new location established in accordance with paragraph (3), or notwithstanding subdivision (e), an FQHC or RHC may choose to have one PPS rate for all locations that appear on its primary care license determined by submitting a change in scope of service request if both of the following requirements are met:
(i)The change in scope of service request includes the costs and visits for those locations for the first full fiscal year immediately following the date the new location is added to the FQHCs or RHCs existing licensee.
(ii)The FQHC or RHC submits the change in scope of service request within 90 days after the FQHCs or RHCs first full fiscal year.
(B)The FQHCs or RHCs single PPS rate for those locations shall be calculated based on the total costs and total visits of those locations and shall be determined based on the following:
(i)An audit in accordance with Section 14170.
(ii)Rate changes based on a change in scope of service request shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successors.
(iii)Any approved increase or decrease in the providers rate shall be retroactive to the beginning of the FQHCs or RHCs fiscal year in which the request is submitted.
(C)Except as specified in subdivision (j), this paragraph does not apply to a location that was added to an existing primary care clinic license by the State Department of Public Health, whether by a regional district office or the centralized application unit, prior to before January 1, 2017.
(3)If an FQHC or RHC does not elect to have the PPS rate determined by a change in scope of service request, the FQHC or RHC shall have the reimbursement rate established for any of the entities identified in paragraph (1) or (2) in accordance with one of the following methods at the election of the FQHC or RHC:
(A)The rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or adjacent area with a similar caseload.
(B)In the absence of three comparable FQHCs or RHCs with a similar caseload, the rate may be calculated on a per-visit basis in an amount that is equal to the average of the per-visit rates of three comparable FQHCs or RHCs located in the same or an adjacent service area, or in a reasonably similar geographic area with respect to relevant social, health care, and economic characteristics.
(C)At a new entitys one-time election, the department shall establish a reimbursement rate, calculated on a per-visit basis, that is equal to 100 percent of the projected allowable costs to the FQHC or RHC of furnishing FQHC or RHC services during the first 12 months of operation as an FQHC or RHC. After the first 12-month period, the projected per-visit rate shall be increased by the Medicare Economic Index then in effect. The projected allowable costs for the first 12 months shall be cost settled and the prospective payment reimbursement rate shall be adjusted based on actual and allowable cost per visit.
(D)The department may adopt any further and additional methods of setting reimbursement rates for newly qualified FQHCs or RHCs as are consistent with Section 1396a(bb)(4) of Title 42 of the United States Code.
(4)In order for an FQHC or RHC to establish the comparability of its caseload for purposes of subparagraph (A) or (B) of paragraph (1), the department shall require that the FQHC or RHC submit its most recent annual utilization report as submitted to the Office of Statewide Health Planning and Development, unless the FQHC or RHC was not required to file an annual utilization report. FQHCs or RHCs that have experienced changes in their services or caseload subsequent to the filing of the annual utilization report may submit to the department a completed report in the format applicable to the prior calendar year. FQHCs or RHCs that have not previously submitted an annual utilization report shall submit to the department a completed report in the format applicable to the prior calendar year. The FQHC or RHC shall not be required to submit the annual utilization report for the comparable FQHCs or RHCs to the department, but shall be required to identify the comparable FQHCs or RHCs.
(5)The rate for any newly qualified entity set forth under this subdivision shall be effective retroactively to the later of the date that the entity was first qualified by the applicable federal agency as an FQHC or RHC, the date a new facility at a new location was added to an existing FQHC or RHC, or the date on which an existing FQHC or RHC was relocated to a new site. The FQHC or RHC shall be permitted to continue billing for Medi-Cal covered benefits on a fee-for-service basis under its existing provider number until it is informed of its FQHC or RHC enrollment approval, and the department shall reconcile the difference between the fee-for-service payments and the FQHCs or RHCs prospective payment rate at that time.
(j)(1)Visits occurring at an intermittent clinic site, as defined in subdivision (h) of Section 1206 of the Health and Safety Code, of an existing FQHC or RHC, in a mobile unit as defined by paragraph (2) of subdivision (b) of Section 1765.105 of the Health and Safety Code, or at the election of the FQHC or RHC and subject to paragraph (2), a location added to an existing primary care clinic license by the State Department of Public Health prior to before January 1, 2017, shall be billed by and reimbursed at the same rate as the FQHC or RHC that either established the intermittent clinic site or mobile unit, or that held the clinic license to which the location was added prior to before January 1, 2017.
(2)If an FQHC or RHC with at least one additional location on its primary care clinic license that was added by the State Department of Public Health prior to before January 1, 2017, applies for an adjustment to its per-visit rate based on a change in the scope of services provided by the FQHC or RHC as described in subdivision (e), all locations on the FQHCs or RHCs primary care clinic license shall be subject to a scope-of-service adjustment in accordance with either paragraph (2) or (3) of subdivision (i), as selected by the FQHC or RHC.
(3)This subdivision does not preclude or otherwise limit the right of the FQHC or RHC to request a scope-of-service adjustment to the rate.
(k)An FQHC or RHC may elect to have pharmacy or dental services reimbursed on a fee-for-service basis, utilizing the current fee schedules established for those services. These costs shall be adjusted out of the FQHCs or RHCs clinic base rate as scope-of-service changes. An FQHC or RHC that reverses its election under this subdivision shall revert to its prior rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with applicable scope-of-service adjustments as provided in subdivision (e).
(l)Reimbursement for Drug Medi-Cal services shall be provided pursuant to this subdivision.
(1)An FQHC or RHC may elect to have Drug Medi-Cal services reimbursed directly from a county or the department under contract with the FQHC or RHC pursuant to paragraph (4).
(2)(A)For an FQHC or RHC to receive reimbursement for Drug Medi-Cal services directly from the county or the department under contract with the FQHC or RHC pursuant to paragraph (4), costs associated with providing Drug Medi-Cal services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing Drug Medi-Cal services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering Drug Medi-Cal services the clinic uses different clinical staff at a different location.
(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver Drug Medi-Cal services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering Drug Medi-Cal services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.
(3)If the costs associated with providing Drug Medi-Cal services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the Drug Medi-Cal services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.
(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering Drug Medi-Cal services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include Drug Medi-Cal services costs.
(B)An FQHC or RHC may submit requests for scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department shall be retroactive to the first day that Drug Medi-Cal services were rendered and reimbursement for Drug Medi-Cal services was received outside of the PPS rate, but in no case shall the effective date be earlier than January 1, 2018.
(C)The FQHC or RHC may bill for Drug Medi-Cal services outside of the PPS rate when the FQHC or RHC obtains approval as a Drug Medi-Cal provider and enters into a contract with a county or the department to provide these services pursuant to paragraph (4).
(D)Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F)For purposes of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and Drug Medi-Cal services.
(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate and the FQHC or RHC is approved as a Drug Medi-Cal provider, an FQHC or RHC shall not bill the PPS rate for any Drug Medi-Cal services provided pursuant to a contract entered into with a county or the department pursuant to paragraph (4).
(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4)Reimbursement for Drug Medi-Cal services shall be determined according to subparagraph (A) or (B), depending on whether the services are provided in a county that participates in the Drug Medi-Cal organized delivery system (DMC-ODS).
(A)In a county that participates in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county or county designee and the FQHC or RHC. If the county or county designee refuses to contract with the FQHC or RHC, the FQHC or RHC may follow the contract denial process set forth in the Special Terms and Conditions.
(B)In a county that does not participate in the DMC-ODS, the FQHC or RHC shall receive reimbursement pursuant to a mutually agreed upon contract entered into between the county and the FQHC or RHC. If the county refuses to contract with the FQHC or RHC, the FQHC or RHC may request to contract directly with the department and shall be reimbursed for those services at the Drug Medi-Cal fee-for-service rate.
(5)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments for Drug Medi-Cal services made pursuant to this subdivision.
(6)For purposes of this subdivision, the following definitions apply:
(A)Drug Medi-Cal organized delivery system or DMC-ODS means the Drug Medi-Cal organized delivery system authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions.
(B)Special Terms and Conditions has the same meaning as set forth in subdivision (o) of Section 14184.10.
(m)Reimbursement for specialty mental health services shall be provided pursuant to this subdivision.
(1)An FQHC or RHC and one or more mental health plans that contract with the department pursuant to Section 14712 may mutually elect to enter into a contract to have the FQHC or RHC provide specialty mental health services to Medi-Cal beneficiaries as part of the mental health plans network.
(2)(A)For an FQHC or RHC to receive reimbursement for specialty mental health services pursuant to a contract entered into with the mental health plan under paragraph (1), the costs associated with providing specialty mental health services shall not be included in the FQHCs or RHCs per-visit PPS rate. For purposes of this subdivision, the costs associated with providing specialty mental health services shall not be considered to be within the FQHCs or RHCs clinic base PPS rate if in delivering specialty mental health services the clinic uses different clinical staff at a different location.
(B)If the FQHC or RHC does not use different clinical staff at a different location to deliver specialty mental health services, the FQHC or RHC shall submit documentation, in a manner determined by the department, that the current per-visit PPS rate does not include any costs related to rendering specialty mental health services, including costs related to utilizing space in part of the FQHCs or RHCs building, that are or were previously calculated as part of the clinics base PPS rate.
(3)If the costs associated with providing specialty mental health services are within the FQHCs or RHCs clinic base PPS rate, as determined by the department, the specialty mental health services costs shall be adjusted out of the FQHCs or RHCs per-visit PPS rate as a change in scope of service.
(A)An FQHC or RHC shall submit to the department a scope-of-service change request to adjust the FQHCs or RHCs clinic base PPS rate after the first full fiscal year of rendering specialty mental health services outside of the PPS rate. Notwithstanding subdivision (e), the scope-of-service change request shall include a full fiscal year of activity that does not include specialty mental health costs.
(B)An FQHC or RHC may submit requests for a scope-of-service change under this subdivision only within 90 days following the beginning of the FQHCs or RHCs fiscal year. Any scope-of-service change request under this subdivision approved by the department is retroactive to the first day that specialty mental health services were rendered and reimbursement for specialty mental health services was received outside of the PPS rate, but the effective date shall not be earlier than January 1, 2018.
(C)The FQHC or RHC may bill for specialty mental health services outside of the PPS rate when the FQHC or RHC contracts with a mental health plan to provide these services pursuant to paragraph (1).
(D)Within 90 days of receipt of the request for a scope-of-service change under this subdivision, the department shall issue the FQHC or RHC an interim rate equal to 90 percent of the FQHCs or RHCs projected allowable cost, as determined by the department. An audit to determine the final rate shall be performed in accordance with Section 14170.
(E)Rate changes based on a request for scope-of-service change under this subdivision shall be evaluated in accordance with Medicare reasonable cost principles, as set forth in Part 413 (commencing with Section 413.1) of Title 42 of the Code of Federal Regulations, or its successor.
(F)For the purpose of recalculating the PPS rate, the FQHC or RHC shall provide upon request to the department verifiable documentation as to which employees spent time, and the actual time spent, providing federally qualified health center services or rural health center services and specialty mental health services.
(G)After the department approves the adjustment to the FQHCs or RHCs clinic base PPS rate, an FQHC or RHC shall not bill the PPS rate for any specialty mental health services that are provided pursuant to a contract entered into with a mental health plan pursuant to paragraph (1).
(H)An FQHC or RHC that reverses its election under this subdivision shall revert to its prior PPS rate, subject to an increase to account for all Medicare Economic Index increases occurring during the intervening time period, and subject to any increase or decrease associated with the applicable scope-of-service adjustments as provided for in subdivision (e).
(4)The department shall not reimburse an FQHC or RHC pursuant to subdivision (h) for the difference between its per-visit PPS rate and any payments made for specialty mental health services under this subdivision.
(n)The department shall seek any necessary federal approvals and issue appropriate guidance to allow an FQHC or RHC to bill, under a supervising licensed behavioral health practitioner, for an encounter between an FQHC or RHC patient and an associate clinical social worker or associate marriage and family therapist when all of the following conditions are met:
(1)The associate clinical social worker or the associate marriage and family therapist is supervised by the licensed behavioral health practitioner, as required by the Board of Behavioral Sciences.
(2)The visit is billed under the supervising licensed behavioral health practitioner of the FQHC or RHC.
(3)The FQHC or RHC is otherwise authorized to bill for services provided by the supervising licensed behavioral health practitioner as a separate visit.
(o)FQHCs and RHCs may appeal a grievance or complaint concerning ratesetting, scope-of-service changes, and settlement of cost report audits, in the manner prescribed by Section 14171. The rights and remedies provided under this subdivision are cumulative to the rights and remedies available under all other provisions of law of this state.
(p)The department shall promptly seek all necessary federal approvals in order to implement this section, including any amendments to the state plan. To the extent that any element or requirement of this section is not approved, the department shall submit a request to the federal Centers for Medicare and Medicaid Services for any waivers that would be necessary to implement this section.
(q)The department shall implement this section only to the extent that federal financial participation is available.
(r)Notwithstanding any other law, the director may, without taking regulatory action pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, implement, interpret, or make specific subdivisions (l) and (m) by means of a provider bulletin or similar instruction. The department shall notify and consult with interested parties and appropriate stakeholders in implementing, interpreting, or making specific the provisions of subdivisions (l) and (m), including all of the following:
(1)Notifying provider representatives in writing of the proposed action or change. The notice shall occur, and the applicable draft provider bulletin or similar instruction, shall be made available at least 10 business days prior to before the meeting described in paragraph (2).
(2)Scheduling at least one meeting with interested parties and appropriate stakeholders to discuss the proposed action or change.
(3)Allowing for written input regarding the proposed action or change, to which the department shall provide summary written responses in conjunction with the issuance of the applicable final written provider bulletin or similar instruction.
(4)Providing at least 60 days advance notice of the effective date of the proposed action or change.
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| Feb 1, 2024 | From committee: Filed with the Chief Clerk pursuant to Joint Rule 56. |
| Jan 31, 2024 | Died pursuant to Art. IV, Sec. 10(c) of the Constitution. |
| May 18, 2023 | In committee: Held under submission. |
| May 18, 2023 | Joint Rule 62(a), file notice suspended. (Page 1580.) |
| May 17, 2023 | In committee: Set, first hearing. Referred to APPR. suspense file. |
| May 1, 2023 | Re-referred to Com. on APPR. |
| Apr 27, 2023 | Read second time and amended. |
| Apr 26, 2023 | From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 15. Noes 0.) (April 25). |
| Mar 27, 2023 | Re-referred to Com. on HEALTH. |
| Mar 23, 2023 | From committee chair, with author's amendments: Amend, and re-refer to Com. on HEALTH. Read second time and amended. |
| Mar 23, 2023 | Referred to Com. on HEALTH. |
| Feb 18, 2023 | From printer. May be heard in committee March 20. |
| Feb 17, 2023 | Read first time. To print. |
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| Apr 25, 2023 | Do pass as amended and be re-referred to the Committee on [Appropriations] | Assembly Standing Committee on Health |
Passed |
This list shows positions taken on this bill by organizations on the date displayed, which is linked to the original source.
Positions by individuals are not included.
|
Organization
|
Position
|
Date
|
|---|---|---|
| Aliados Health | ** Support | |
| AltaMed Health Services | ** Support | |
| APLA Health | ** Support | |
| Arroyo Vista Family Health Center | ** Support | |
| Asian Health Services | ** Support | |
| Axis Community Health | ** Support | |
| Bartz-Altadonna Community Health Center | ** Support | |
| Behavioral Health Services, INC. | ** Support | |
| California Academy of Family Physician | * Support | Apr 25, 2023 |
| California Health Plus Advocates | * Support | Apr 25, 2023 |
| California Primary Care Association | * Support | Apr 25, 2023 |
| Center for Family Health & Education, INC | ** Support | |
| Central City Community Health Center | ** Support | |
| Central Neighborhood Health Foundation | ** Support | |
| Community Clinic Association | * Support | Apr 25, 2023 |
| Community Medical Wellness Centers, USA | ** Support | |
| East Valley Community Health Center | ** Support | |
| Eisner Health | ** Support | |
| El Proyecto del Barrio, Inc. | ** Support | |
| Elica Health Centers | ** Support | |
| Harmony Health | ** Support | |
| Health Alliance of Northern California | ** Support | |
| Health Center Partners of Southern California | ** Support | |
| Herald Christian Health Center | ** Support | |
| La Clinica de La Raza, Inc. | ** Support | |
| Los Angeles LGBT Center | ** Support | |
| Neighborhood Healthcare | ** Support | |
| North Coast Clinics Network | ** Support | |
| North East Medical Services | ** Support | |
| Northeast Valley Health Corporation | ** Support | |
| Park Tree Community Health Center | ** Support | |
| Saban Community Clinic | ** Support | |
| Salud Para La Gente | ** Support | |
| Santa Cruz Community Health | ** Support | |
| Shasta Community Health Center | ** Support | |
| South Central Family Health Center | ** Support | |
| St. Johns Well Child & Family Health Center | ** Support | |
| St. Jude Neighborhood Health Centers | ** Support | |
| T.H.E. Health and Wellness Center | ** Support | |
| Tarzana Treatment Centers, Inc. | ** Support | |
| TCC Family Health | ** Support | |
| UMMA Community Clinic | ** Support | |
| Venice Family Clinic | ** Support |
Date of Hearing: May 17, 2023
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Chris Holden, Chair
ABPCA Bill Id:AB 1549
Author:(Wendy Carrillo) – As Amended Ver:April 27, 2023
Policy Committee: | Health | Vote: | 15 - 0 |
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Urgency: No State Mandated Local Program: No Reimbursable: No
SUMMARY:
This bill revises the prospective payment system (PPS) per-visit rate calculation to account for staffing and care delivery models for Medi-Cal services provided by Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) (collectively, health centers). This bill also revises the definition of change in scope of service to include visit duration, intensity, and amount of activities provided, among other provisions.
FISCAL EFFECT:
Costs of an unknown, but likely significant amount, to the Department of Health Care Services (DHCS) to determine how to implement this bill, promulgate regulations, and provide necessary guidance to health centers. Additionally, significant cost pressure, potentially in the tens of millions or hundreds of millions of dollars annually, if the PPS update results in health centers being able to recover greater reimbursement for care they provide (General Fund, federal funds).
COMMENTS:
- Purpose. According to the author:
AB 1549 would update the Prospective Payment System (PPS) for Community Based Health Centers (CHCs) to reflect their investment in patient outcomes and whole-person care initiatives. Millions of Californians depend on CHCs. This bill would add the addition of expanded care team members to the list of triggers that would allow a CHC to ask the Department of Health Care Services (DHCS) to re-evaluate the clinic’s PPS rate. By making this change, the state can make CHCs a more effective partner in the California Advancing and Innovating Medi-Cal (CalAIM) initiative, an approach that advances health equity by providing culturally competent services.
This bill is sponsored by California Health+ Advocates, which states this bill seeks to modernize PPS to ensure health centers have the tools to meet the state-led care transformation efforts providing whole-person care to our patients and communities.
- Efforts towards an Alternative Payment Model (APM). Under federal Medicaid law, states may use an APM that pays at least what the health center would receive under the PPS on an aggregate basis. In 2014, DHCS attempted to authorize a three-year payment reform pilot project for FQHCs using an APM authorized under federal Medicaid law. However, the approach did not receive federal approval and DHCS announced in February 2018 it had paused implementation for the foreseeable future.
Senate Bill 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2022, updated and modified the relevant APM statutes, and DHCS has been working with stakeholders to implement the APM. According to a September 2022 FQHC APM overview document, DHCS expects the APM go live January 1, 2024. The stated purpose of the APM is to allow innovative payment reform and quality of care improvement, as well as to implement flexible payment reform, to permit and expand innovative care not reimbursed under traditional volume-based PPS. According to DHCS, FQHCs participating in the APM would be able to move away from the traditional PPS to a front-loaded reimbursement methodology that more closely aligns with evolving practice needs and the effective delivery of health care services. Each participating FQHC will receive monthly payments equivalent to their total, projected PPS payment entitlement in the form of an APM per member, per month (PMPM) rate, paid across all assigned members attributable to each Medi-Cal managed care plan with whom the participating health center has contracted. Upon implementation, DHCS will be including necessary PMPM rates in monthly capitation paid to plans, who will then be expected to remit appropriate PMPM payments to participating FQHCs who have provided covered services to their Medi-Cal members. DHCS states the new APM methodology will be linked to specific quality metrics that must be satisfied by the participating FQHC as a condition of continued participation in the APM program.
Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081
Date of Hearing: April 25, 2023
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
ABPCA Bill Id:AB 1549
Author:((Wendy Carrillo) – As Amended Ver:March 23, 2023
SUBJECT: Medi-Cal: federally qualified health centers and rural health health centers.
SUMMARY: Modifies several provisions related to rate-setting for the prospective payment system (PPS) per-visit rate for Medi-Cal services provided by Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) (collectively, health centers). Broadens and redefines “change in scope of services,” a process by which a health center may seek a recalculation of their PPS rate. Specifically, this bill:
- Requires the PPS rate to account for the costs of the health center that are reasonable and related to the provision of covered services, including the specific methods and processes used by the health center to deliver those services.
- Requires rate changes to be evaluated according to federal “Uniform Guidance,” as specified, instead of Medicare reasonable cost principles.
- Broadens and re-casts the current-law definition of change in scope of services as follows:
- Recasts the current-law definition of change in scope of services, changing the definition from one that lists a discrete number of allowable scenarios that would constitute a change in scope of services, to a definition that includes, but is not limited to, the specific scenarios;
- Redefines a change in the scope of services as a change in the type of covered services provided by a health center at a particular site, or a change in methods or processes utilized by a health center to provide covered services, that results in an increase or decrease in any of the following:
- The intensity of activities taking place in an average visit that are reasonable and related to the provision of covered services;
- The length or duration of an average visit; or,
- The amount of activities provided by a health center in an average visit that are reasonable or related to the provision of covered services.
- Adds the following as scenarios that would trigger a change in scope of services:
- A change related to Medi-Cal managed care plan contracting that either directly or indirectly impacts a health center; and,
- The addition or deletion of a service or a change in service necessary to comply with the Medi-Cal state plan.
- Further specifies the following scenarios that constitute a change in scope of services under current law:
- Specifies the addition of new services is inclusive of care coordination services, as further described in f) below;
- Specifies a change related to applicable technology includes upgrades, replacements, or replacements to existing technology;
- Prohibits, for purposes of defining whether a change in costs constitutes a change in scope, the application of cost caps or productivity screens; and,
- Prohibits federal guidance documents not specifically identified in statute from being used by the Department of Health Care Services (DHCS) to determine the allowable costs of the health center.
- Requires an adjustment to the health center’s per-visit rate based on an approved scope-of-service change to account for 100% of the newly established cost per visit, as determined from the cost report filed by the health center.
- Further defines care coordination as a service a health center may add and/or include, for purposes of a change in scope of service, as follows:
- Requires care coordination services to be provided by individuals trained as, and with specific titles including, but not limited to, care coordinators, case managers, referral coordinators, or other titles including, but not limited to, nurses, social workers, and other professional staff who are specifically allocated to care coordination during assigned hours, but not when these services are an integral part of their other duties including providing direct patient care.
- Defines care coordination as the deliberate organization of patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care, and specifies care coordination includes, but is not limited to:
- Coordination of covered services;
- Arranging for transportation to and from a source of medical care;
- Patient education regarding covered services, the benefits of preventive medical and dental care, and how to efficiently utilize the health care system and access services;
- Prenatal education or health education;
- Referral for services, community resources, or other agencies for needed services or items;
- Assistance to ensure client compliance with services prescribed or recommended services, including, but not limited to, substance abuse treatment, early intervention services, behavioral health, and specialty care; and,
- Facilitating communication among the patient’s health care providers, including, but not limited to, behavioral health and substance abuse providers when appropriate.
- Prohibits DHCS from modifying a “wrap payment” by the amount of a financial or quality incentive payment paid from a managed care plan to a health center, regardless of whether federal law allows DHCS to modify the wrap payment to account for such incentive payments.
EXISTING FEDERAL LAW:
- PPS Rate. Establishes the PPS rate by requiring, for health center services furnished on and after January 1, 2001, during federal fiscal year 2001, a Medicaid State plan to provide for payment for such services in an amount (calculated on a per-visit basis) that is equal to 100 percent of the average of the costs of the health center of furnishing such services during fiscal years 1999 and 2000 which are reasonable and related to the cost of furnishing such services, or based on such other tests of reasonableness as the federal Health and Human Services prescribes in regulations, adjusted to take into account any increase or decrease in the scope of such services furnished by the health center during fiscal year 2001. Makes certain exceptions, as specified. [42 United States Code (U.S.C.) § 1396a(bb)(2)]
- Update of PPS Rate. Establishes a process to update the PPS rate by requiring, for health centers and RHC services furnished in federal fiscal year 2002 and succeeding fiscal years, for services furnished during fiscal year 2002 or a succeeding fiscal year, the Medicaid State plan to provide for payment for such services in an amount (calculated on a per-visit basis) that is equal to the amount calculated for such services for the preceding fiscal year, and:
- Increased by the percentage increase in the Medicare Economic Index applicable to primary care services for that fiscal year, as specified; and,
- Adjusted to take into account any increase or decrease in the scope of such services furnished by the health center during that fiscal year. [42 U.S.C. § 1396a(bb)(3)]
- Initial year PPS. Establishes an initial year PPS rate for new health centers by requiring, in any case in which an entity first qualifies as a health center after fiscal year 2000, the Medicaid State plan to provide for payment in an amount (calculated on a per visit basis) that is equal to 100% of the costs of furnishing such services during such fiscal year based on the rates established under this subsection for the fiscal year for other such health centers located in the same or adjacent area with a similar caseload or, in the absence of such a health center, in accordance with specified regulations and methodology, and requires, in subsequent years, the state to provide for the payment amount to be calculated in accordance with 2) above. [42 U.S.C. § 1396a(bb)(4)]
EXISTING STATE LAW:
- Establishes the Medi-Cal Program, administered by DHCS, to provide comprehensive health benefits to low-income individuals who meet specified eligibility criteria. [Welfare and Institutions Code (WIC) § 14000 et seq.]
- Establishes health center services, as described in federal law, as covered Medi-Cal benefits. [Welfare and Institutions Code § 14132.100]
- Requires health centers to be reimbursed on a per-visit basis. [Ibid.]
- Defines a “visit” as a face-to-face encounter between a health center patient and the following health care providers:
- Physician;
- Physician Assistant;
- Nurse Practitioner;
- Certified Nurse Midwife;
- Clinical Psychologist;
- Licensed Clinical Social Worker;
- Visiting Nurse;
- Dental Hygienist;
- Dental Hygienist in Alternative Practice;
- Marriage And Family Therapist;
- Podiatrist;
- Dentist;
- Optometrist;
- Chiropractor;
- Comprehensive Perinatal Services Practitioner providing comprehensive perinatal services;
- Four-hour day of attendance at an Adult Day Health Care Center; or
- Any other Provider identified in the state plan’s definition of a health center visit. [Ibid.]
- Requires health center per-visit rates to be increased by the Medicare Economic Index (MEI) applicable to primary care services in the manner provided for in federal law. [Ibid.]
- Permits a health center to apply for an adjustment to its per-visit rate based on a change in the scope of services provided by the health center. Requires rate changes based on a change in the scope of services provided by a health center to be evaluated in accordance with Medicare reasonable cost principles, as defined in federal regulation. [Ibid.]
- Specifies nine circumstances constituting a change in scope of services, including the addition or deletion of a services, changes in services due to remodeling or relocating, increases in service intensity attributable to change in patient population, a change in types of services due to a change in applicable technology and medical practice, and costs related to medical education. [Ibid.]
- Requires, in order for a change in costs to elicit a change in scope of services, the net change in the health center’s rate to equal or exceed 1.75% for the affected health center site. [Ibid.]
- Allows a health center to submit requests for scope-of-service changes once per fiscal year, only within 90 days following the beginning of the health center’s fiscal year. [Ibid.]
FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.
COMMENTS:
- PURPOSE OF THIS BILL. According to the author, this bill is intended to update the PPS rate process for health centers to reflect their investment in patient outcomes and whole-person care initiatives. The author indicates this bill would allow a health center to ask DHCS to re-evaluate the health center’s PPS rate upon the addition of expanded care team members. By making this change, the state can make health centers a more effective partner in the California Advancing and Innovating Medi-Cal (CalAIM) initiative, an approach that advances health equity by providing culturally competent services. The author indicates DHCS has excluded many reasonable costs incurred by health centers. This bill is sponsored by California Health+ Advocates, the advocacy organization representing health centers.
- BACKGROUND
- FQHCs and RHCs. FQHCs and RHCs are federally designated health centers that receive federal grant funding under Section 330 of the Public Health Service Act. These health centers are core providers in the Medi-Cal program as well as serving as a health care safety net within communities. Health centers are required to provide primary care services regardless of ability to pay; services are provided on a sliding scale fee based on ability to pay. There over 1,000 FQHCs and nearly 300 RHCs in California. The number of health centers in California has grown significantly. In 2006, there were 476 FQHC service sites.
- PPS. Because of their unique role in providing health care to underserved communities and the uninsured, policymakers have historically attempted to ensure health centers remain financially viable. Section 330 grants provide funding for uncompensated care, and federal law established the PPS methodology to ensure state Medicaid agencies compensate health centers for the full cost of care for Medicaid patients. States also may implement an alternative method (APM) that pays the same or more than the federal PPS.
A PPS rate is a health center-specific per-visit rate. Although calculation of a PPS rate is highly technical, it can be generally thought of as an average per-visit cost, derived by dividing costs for Medi-Cal-reimbursable services by Medi-Cal billable visits. A PPS rate is also adjusted annually by an economic inflator, the MEI. DHCS’ Medi-Cal Estimate indicates the MEI rate increase percent was 4.36% for calendar year (CY) 2021 and 4.06% for CY 2022, and is projected at 4.06% for CY 2023. In addition to the annual inflator, a health center can request a recalculation of its PPS rate based on a change in its scope of services, discussed further in c) below.
Each health center has a specific Medi-Cal PPS rate for each encounter, irrespective of the reason for the visit. All health centers must provide at least a defined scope of primary care and mental health services, but may provide additional services as well. Clinics can only bill the PPS rate when the encounter with a patient is with one of a specified list of providers. (See 6) above in Existing State Law).
As of May 2022, the mean and median rate for health center services was approximately $227 and $217, respectively.
This bill requires the PPS rate to account for the costs of the health center that are reasonable and related to the provision of covered services, including the specific methods and processes used by the health center to deliver those services. According to California Health+ Advocates, this bill’s sponsor, the insertion of “reasonable and related to the provision of covered services” is meant to align with federal law noted in Existing Federal Law, 1) above. The practical effect of adding the “specific methods and processes used by the health center to deliver those services” is unclear.
- Change in Scope of Service.
- In General. After a PPS rate is established for a health center, federal law requires states to take into account any increase or decrease in the scope of services furnished by the health center during that fiscal year, in addition to adjusting the rates for a particular fiscal year based on the MEI as discussed in b) above.
- Change in Scope of Service.
According to a brief by the National Association of Community Health Centers (NACHC), “Defining an Effective Medicaid Change in-Scope Rate Adjustment Process for Health Centers,” a state’s definition of a change in scope of service should, at minimum, include the four types of changes listed in 2001 federal guidance: changes in type, intensity, duration, and amount of services. NACHC indicates these four types of changes are not included in all states’ definitions.
Optimally, according to NACHC, states should include in their policies a detailed, non-exclusive list of qualifying events that would qualify as each of the four categories of changes (i.e., the definition should indicate that the list of events “includes, but is not limited to….”).
NACHC lists examples of the four types of qualifying events for a change in scope:
- Change in Type: A health center chooses to offer a new discrete service that is covered under the state plan, and which has not been previously incorporated into its PPS rate.
- Change in Intensity: A health center adds new clinic equipment, resulting in more resource-intensive visits (e.g., cardiac stress tests added as feature of adult wellness visits), or new supporting staff, resulting in more resource-intensive visits (e.g., behavioral health consultant included in well-child visits), or new technology relating to care (e.g., new practice management or electronic health record system).
- Change in Duration: A health center’s patient population mix changes (e.g., increase in adult patients due to Medicaid expansion), resulting in more services/procedures performed per visit and greater average time per visit.
- Change in Amount: A health center develops new protocols that result in more services or procedures being performed in one visit and greater average time per visit (e.g., combined medical and behavioral health visits).
- Existing Law and Practice in California. State law sets forth multiple types of events that trigger the ability, or a requirement, for health center to submit a change in scope of service request (CSOSR). Examples include:
- The addition of a new health center service that is not incorporated in the baseline PPS rate;
- The deletion of a health center service that is incorporated in the baseline PPS rate;
- A change in service due to amended regulatory requirements or rules;
- A change in service resulting from relocating or remodeling a health center; or,
- An increase in service intensity attributable to changes in the types of patients served.
Although it could be debated what constitutes a change in duration versus intensity or amount (e.g., if a higher “amount” of services are provided, visits will also be longer), the existing law appears to capture scenarios consistent with the spirit of federal law. However, this bill’s sponsor asserts that over time, DHCS has limited this broad requirement to recognize changes in duration, intensity, and amount of services by applying an increasingly narrow statutory interpretation, leading to DHCS ignoring these concepts and allowing adjustments to a PPS rate only if a health center offers a new type of service.
Because the CSOSR requires a state audit, it may result in a lower PPS rate, and is time-consuming to process, health centers are sometimes reluctant to submit a CSOSR. Fewer than 10% of health centers applied for a CSOSR annually over the last several years. Most CSOSRs result in a PPS rate increase.
- Effect of this Bill on CSOSRs. Overall, the changes made by this bill appear to make it easier for a health center to make the case to adjust their rates pursuant to a change in scope of services and ensure more of the health center’s costs are counted for purposes of rate development.
- Implementation of New Definition of Change in Scope of Services. However, the effect of the bill would somewhat depend on DHCS’s interpretation and implementation. For instance, this bill changes the definition of a change in scope of services from one that lists a discrete number of allowable scenarios that would constitute a change in scope of services, to a definition that includes, but is not limited to, the listed scenarios. It is unclear whether keeping the scenarios open-ended in statute would allow health centers to submit a CSOSR based on any change they believed was within the general parameters of an increase in duration, intensity, type, or amount, or if DHCS would further define or limit the triggering events by regulation.
- Adding or Deleting Services. This bill also allows a CSOSR based on “addition or deletion of a service or a change in service necessary to comply with the Medi-Cal state plan.” This provision is also not straightforward to interpret, because health center services are themselves defined in the state plan. It is unclear whether a CSOSR could be triggered based solely on a change in the definition of health center services in the state plan, or the addition or deletion of other services defined in the state plan.
- Care Coordination. The explicit addition of care coordination services to trigger a change in scope of services would appear to allow health centers to capture the cost for those services. Some of these services are likely already reflected in a health center’s PPS rate, but a recalculated PPS rate pursuant to a CSOSR would likely more comprehensively capture the costs a health center attributes to these services.
- Cost-Efficiency. Some of the provisions appear to limit DHCS’s flexibility to encourage more cost-efficiency. The bill prohibits, for example, the application of cost caps or productivity screens for purposes of defining whether a change in costs constitutes a change in scope. It also prohibits federal guidance documents not specifically identified in statute from being used by DHCS to determine the allowable costs of the health center. The effect of the prohibition of federal guidance documents is unclear, but it appears intended to limit the application of federal guidance that could constrain health center costs. Finally, the provision requiring an adjustment to the health center’s per-visit rate based on an approved scope-of-service change to account for 100% of the newly established cost per visit eliminates the current practice of DHCS applying a 20% reduction to the increased costs.
- Other Changes. Under this bill, a health center could apply for a CSOSR based on “a change related to a Medi-Cal managed care plan contracting that either directly or indirectly impacts a health center.” As above, DHCS could further define or narrow these scenarios through regulation, or it could allow for almost any health center to submit a CSOSR, given the broadness of language like a “change related to Medi-Cal managed care contracting.”
- Effect of this Bill on CSOSRs. Overall, the changes made by this bill appear to make it easier for a health center to make the case to adjust their rates pursuant to a change in scope of services and ensure more of the health center’s costs are counted for purposes of rate development.
Taken together, the changes would appear to encourage a larger number of health centers to submit a CSOSR, increase those health centers’ PPS rates, limit DHCS’s attempts to contain Medi-Cal costs or promote cost-efficiency for this provider type, and allow those health centers to expand care coordination and other services.
- Wraparound (“Wrap”) Payments. Federal law requires health centers that participate in managed care networks to receive payment that is at least equal to the PPS per-visit payment in the aggregate. A wraparound, or wrap, payment is made by DHCS to a health center to “make the health center whole” when managed care plans reimburse the health center less than the PPS rate.
Medi-Cal managed care plans have flexibility in how they pay for health center services and are not required to use the PPS rate methodology, although plans are required to pay health centers at least what they would pay non- health center providers in their network for the same medical services. When total managed care plan payments to a health center are less than what the health center would have been paid under the PPS or APM amount, the state Medicaid agency must pay the difference. This is called the wrap payment.
To meet the state’s Medi-Cal health care quality improvement goals, managed care plans can offer incentive payments to providers to drive specific behaviors consistent with such goals. However, incentive payments from plans to providers pose fiscal and policy questions in the context of the rigid PPS rate methodology, given the wrap payment paid by the state essentially fills in any gap between the managed care payment rates and the PPS rate. This puts plans and health centers in a predicament where if managed care plans pay incentive payments to health centers to drive specific behavior, the effect of such payments can be erased if the state’s wrap payment is offset by the amount of the incentive payments.
According to California Health+ Advocates, DHCS has taken the position that while financial incentives should not be offset from Medi-Cal’s liability in the wrap-around process, quality incentives should be offset. California Health+ Advocates asserts this eliminates incentives for the health center to improve the quality of care.
As a simplified example to illustrate the concept, if this bill’s provisions were in place for a health center whose PPS rate is $200, if a managed care plan paid $100 for a service and also offered a $50 incentive payment, the health center would be eligible for the $100 wrap payment from DHCS ($200 PPS rate minus the $100 managed care payment) and could also, separately, retain the $50 incentive payment. Specifically:- Under current practice, according to California Health+ Advocates, DHCS would reduce the amount due for the wrap payment by $50, and the health center would receive $200 (the $100 managed care payment, plus the $50 incentive payment, plus a $50 wrap payment).
- Under this bill, the health center would receive $250 (the $100 managed care payment, plus the $50 incentive payment, plus a $100 wrap payment).
- APM. States have the option to use an APM, provided that the health center agrees to the method and that the alternative method pays at least what the health center would have received under the PPS on an aggregate basis.
- Wraparound (“Wrap”) Payments. Federal law requires health centers that participate in managed care networks to receive payment that is at least equal to the PPS per-visit payment in the aggregate. A wraparound, or wrap, payment is made by DHCS to a health center to “make the health center whole” when managed care plans reimburse the health center less than the PPS rate.
An APM was first authorized under SB 147 (Hernandez), Chapter 760, Statutes of 2014, which required DHCS to authorize a three-year payment reform pilot project for FQHCs using an APM authorized under federal Medicaid law. However, the approach did not receive federal approval and DHCS announced in February 2018 it had paused implementation for the foreseeable future. More recently, Senate Bill 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2022, updated and modified the relevant APM statutes, and DHCS has been actively working with stakeholders and internally on planning to implement the APM.
Legislative findings and declarations in SB 184 indicate the Legislature’s intent that an APM transition away from a payment system that rewards volume with a flexible alternative that recognizes the value added when Medi-Cal beneficiaries are able to more easily access the care they need and when providers are able to deliver care in the most appropriate manner to patients.
DHCS indicates it is developing the APM for participating FQHCs to incentivize delivery system and practice transformation through the flexibilities available under a fully capitated reimbursement model. According to a September 2022 FQHC APM Overview document, DHCS expects a go-live date of January 1, 2024. The stated purpose of the APM is to allow innovative payment reform and quality of care improvement, as well as to implement flexible payment reform, to permit and expand innovative care not reimbursed under traditional volume-based PPS.
According to DHCS, FQHCs participating in the APM would be able to move away from the traditional PPS to a front-loaded reimbursement methodology that more closely aligns with evolving practice needs and the effective delivery of health care services. Each participating FQHC will receive monthly payments equivalent to their total, projected PPS payment entitlement in the form of an APM per member, per month (PMPM) rate, paid across all assigned members attributable to each Medi-Cal managed care plan with whom the participating health center has contracted. Upon implementation, DHCS will be including necessary PMPM rates in monthly capitation paid to plans, who will then be expected to remit appropriate PMPM payments to participating FQHCs who have provided covered services to their Medi-Cal members.
DHCS states it will also will be implementing safeguards to ensure that participating FQHCs receive their full PPS entitlement. On an annual basis, DHCS will verify payments made to participating FQHCs are sufficient and comply with all APM requirements. In the event the PMPM payments are determined to be inadequate, DHCS will pay the participating FQHC the difference between the total PMPM amount paid and the amount that the entity would have received under the traditional PPS rate methodology.
In order to incentivize enhanced health care quality for impacted Medi-Cal members, DHCS states the new APM methodology will be linked to specific quality metrics that must be satisfied by the participating FQHC as a condition of continued participation in the APM program.
On its website, the California Primary Care Association (CPCA), the membership organization for FQHCs, states it is actively working with the DHCS and other key stakeholders on the APM effort, which will modernize PPS and change how FQHCs will be reimbursed. CPCA echoes DHCS’s assertion the APM will ensure health centers receive at least what they would have gotten under PPS, but with more flexibility for the FQHC and patient. According to CPCA, a modernized payment methodology for FQHCs will align with the implementation of CalAIM and the state’s efforts to promote a more holistic, patient-centered approach to care. CPCA states the APM will modernize PPS by allowing participating FQHCs to move from the visit-based reimbursement methodology to a capitation payment methodology, commonly known as a PMPM payment. According to CPCA, the APM will:
- Provide the flexibility to deliver care in innovative ways that will expand primary and specialty care access and help improve patient experience;
- Simplify the payment processes for health centers alleviating many of the administrative challenges including billing wraparound payment, reconciling payments, etc.; and,
- Facilitate greater collaboration between FQHCs and Medi-Cal managed care plans, specifically in the areas of data collection and submission, care coordination and quality improvement.
- SUPPORT. This bill is supported by numerous individual FQHCs as well as California Health+ Advocates. According to California Health+ Advocates, this bill seeks to modernize PPS to ensure health centers have the tools to meet the state-led care transformation efforts providing whole-person care to our patients and communities. According to California Health+ Advocates, PPS is restrictive and encounter-based, and a health center will only receive its PPS rate if: a) the service is defined as an allowable encounter or set of services as defined under PPS; b) only one billable service is provided to a patient per day (exception is a medical and dental visit can be provided on the same day); and, c) the service is completed by a billable provider (physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, licensed marriage and family therapist, licensed acupuncturist, or a visiting nurse).
According to California Health+ Advocates, California statute only allows a health center to make a CSOSR, essentially requesting a reevaluation of its PPS rate, under strict circumstances. Those ‘triggering events’ do not truly capture the expanded care team members contemplated by CalAIM, the transition to whole-person care and population health management, and the APM. California Health+ Advocates states the APM is a novel approach to incentivize value-based care and practice transformation outside the traditional four corners of a health center using expanded care team members, but current statute does not allow health centers to fully capture these care transformation efforts in their “allowable costs” and ultimately be reflected in their PPS rate.
- RELATED LEGISLATION. SB 282 (Eggman) authorizes reimbursement for a maximum of two visits that take place on the same day at a single site, whether through a face-to-face or telehealth-based encounter, if after the first visit the patient suffers illness or injury that requires additional diagnosis or treatment, or if the patient has a medical visit and either a mental health visit or a dental visit, as defined, and adds a licensed acupuncturist within those health care professionals covered under the definition of a “visit.” SB 282 is pending on the Suspense File of the Senate Appropriations Committee.
- PREVIOUS LEGISLATION.
- SB 316 (Eggman) of 2022 would have required Medi-Cal reimbursement to health centers and RHCs for two visits taking place on the same day at a single location when the patient suffers illness or injury requiring additional diagnosis or treatment after the first visit, or when the patient has a medical visit and another health visit with a mental health or dental provider. SB 316 was not taken up for a vote on the Assembly Floor.
- AB 770 (Eduardo Garcia) of 2019 contained provisions similar to this bill. AB 770 would have require the methodology of the adjusted per-visit rate to exclude, among other things, a provider productivity standard; would have authorized an FQHC or RHC to apply for a rate adjustment for the adoption, implementation, or upgrade of a certified electronic health record system as a change in the scope of service; would have clarify specified terms, including the meaning of “scope of “service;” would have expanded the meaning of “visit” to include FQHC and RHC services rendered outside of the facility location, and would modify how the department reimburses an FQHC or RHC that is partially reimbursed by a 3rd-party payer. It would have also required a health care provider who contracts with an FQHC or RHC to provide services outside of the facility on behalf of the facility, and for which the facility bills for those services, to comply with specified requirements, including actively serving patients in the same county as, or a county adjacent to, the physical location of the billing FQHC or RHC; allowed a health center to file a scope of service rate change to any time during the fiscal year; and would have required the department to ensure that department staff conducting audits related to FQHC and RHC services receive appropriate training on federal and state laws governing those facilities. AB 770 bill was held on the Assembly Appropriations Committee suspense file.
- SB 1125 (Atkins) of 2018 would have required Medi-Cal reimbursement for a maximum of two visits taking place on the same day at a single location of an health center to be reimbursed when the patient has a medical visit and a mental health visit or a dental visit on the same day; and would have made this change continent upon an appropriation in the annual Budget Act. SB 1125 was vetoed by Governor Brown with five other bills in the same veto message, who indicated that each of those bills require significant, ongoing general fund commitments, and he believed these bills should be considered as part of the budget process.
- AB 2428 (Gonzalez Fletcher), Chapter 762, Statutes of 2018, allows a health center that adds an additional physical plant to its primary care license to elect to have the Medi-Cal reimbursement rate for each new plant be billed at and reimbursed at the same rate as the health center.
- AB 1591 (Berman) of 2017 would have added licensed professional clinical counselors to the list of health care professionals that qualify for a face-to-face encounter with a patient at health centers for purposes of a per-visit Medi-Cal payment under PPS. AB 1591 was vetoed by the Governor, who stated that DHCS is developing a new payment model (APM) for these health centers that will eliminate the need to add specific providers to an approved list, thus making AB 1591 unnecessary.
- SB 456 (Pan) of 2017 would have required compensation paid to a health center for services that follow the patient (as defined) to be supplemental to, and separate from, the health center’s PPS rate and not subject to a reconciliation or to any reduction. SB 456 was held on the Assembly Appropriations Committee suspense file.
- AB 1863 (Wood), Chapter 610, Statutes of 2016, added licensed Marriage and Family Therapists (MFTs) as providers who are permitted to bill for visits at a health centers or RHC so long as the health center files for a change in scope of services with DHCS and the change is approved.
- AB 858 (Wood) of 2015 would have included a provision that added MFTs to the list of health care professionals that could bill Medi-Cal for purposes of a health center visit. SB 858 was vetoed by Governor Brown who said it would require new spending at a time when there was considerable uncertainty in the funding of this program.
- SB 147 required DHCS to authorize a three-year payment reform pilot project for FQHCs using an APM authorized under federal Medicaid law. SB 147 also requires an FQHC participating in the pilot to receive a PMPM payment for each of its APM enrollees from a Medi-Cal managed care health plan, instead of the wrap around payment FQHCs currently receive from DHCS.
- SB 184 made updates to the APM statute enacted in SB 147.
- AMENDMENTS. Following conversations between the Committee, author, and sponsors, the author has agreed to amend this bill to address several substantive and clarifying issues, as follows:
- Cost Caps and Productivity Screens. To reduce concern about diminishing DHCS’s authority to ensure cost-effective delivery of services, amendments delete the prohibition on application of cost caps and productivity screens.
- Prohibition on the Application of Federal Guidance. This bill prohibits DHCS from applying federal guidance documents not specifically identified in statute to determine the allowable costs of a health center. However, federal guidance documents may exist or be issued that are relevant to how DHCS defines these costs, and prohibiting their use could restrict DHCS’s ability to implement the program pursuant to federal rules. To address this concern, amendments remove this provision and instead require DHCS to identify through published guidance any federal guidance documents not specifically identified in law, that are used to define allowable costs or otherwise describe the change in scope of services process to determine the allowable costs of the health center.
- Clarifying Amendments. Amendments make the following clarifying changes:
- The bill requires the per-visit costs to account for the costs of the health center that are reasonable and related to the provision of covered services, including the specific methods and processes used to deliver care. To clarify the author’s intent, amendments replace “methods and processes” with “staffing and care delivery models.”
- Amendments clarify the bill’s redefinition of change in scope of services by striking the added definition and instead integrating the added concepts of “intensity, duration, and amount” into the existing definition.
- Amendments clarify the addition of a health center service, for purposes of a CSOSR, includes a change in services based on services added to or deleted from the Medi-Cal state plan, whether or not the service is explicitly delineated in the state plan as a health center service.
REGISTERED SUPPORT / OPPOSITION:
Support
California Health+ Advocates (subsidiary of the California Primary Care Association) (sponsor)
Aliados Health
Altamed Health Services
APLA Health
Arroyo Vista Family Health Center
Asian Health Services
Axis Community Health
Bartz-Altadonna Community Health Centers
Behavioral Health Services, INC.
California Academy of Family Physicians
Center for Family Health & Education, INC
Central City Community Health Center
Central Neighborhood Health Foundation
Community Clinic Association of Los Angeles County (CCALAC)
Community Medical Wellness Centers, USA
East Valley Community Health Center
Eisner Health
El Proyecto Del Barrio, INC.
Elica Health Centers
Harmony Health
Health Alliance of Northern California
Health Center Partners of Southern California
Herald Christian Health Centers
La Clinica de La Raza, INC.
Los Angeles LGBT Center
Neighborhood Healthcare
North Coast Clinics Network
North East Medical Services (NEMS)
Northeast Valley Health Corporation
Parktree Community Health Centers
Saban Community Clinic
Salud Para La Gente
Santa Cruz Community Health
Shasta Community Health Center
South Central Family Health Center
St. Johns Well Child & Family Health Center
St. Jude Neighborhood Health Center
T.H.E. (To Help Everyone) Health and Wellness Centers
T.H.E. Health and Wellness Centers
Tarzana Treatment Centers, INC.
TCC Family Health
UMMA Community Clinic
Venice Family Clinic
Opposition
None on file.
Analysis Prepared by: Lisa Murawski / HEALTH / (916) 319-2097
Bill Author
Bill Co-Author(s):