1	NARHC Technical Assistance Call July 22, 2008 CMS 1910 P2: Medicare Program; Changes in Conditions of Participation Requirements and Payment Provisions for Rural Health Clinics and Federally Qualified Health Centers: Proposed Rule
2	NARHC Technical Assistance Call July 8, 2008 CAPT Corinne Axelrod, MPH, LAc, Dipl.Ac Centers for Medicare & Medicaid Services (CMS) Center for Medicare Management (CMM) Hospital and Ambulatory Policy Group (HAPG) Division of Ambulatory Services (DAS) 410-786-5620 corinne.axelrod@cms.hhs.gov
3	Agenda I. Staffing Requirements, Waivers, & Contracts II. Payment Issues III. Additional Resources IV. Q & A
4	I. Staffing Requirements Special Requirements for RHCs 1. Must have an NP, PA, or CNM at least 50% of the time the clinic operates (OBRA ’89) 2. Must employ one or more NP or PA
5	1. Must have an NP, PA, or CNM at least 50% of the time the clinic operates Does not include the time that an RHC is open solely to address administrative matters or provide shelter Existing RHCs would be able to apply for a one year waiver of this requirement To be granted a waiver, RHCs would have to demonstrate a good faith effort to recruit and hire an NP, PA, or CNM within the past 90 days
6	1. Must have an NP, PA, or CNM at least 50% of the time the clinic operates RHCs that submit a waiver request would be granted a one year waiver unless they are notified within 60 days that the request is denied Would be able to reapply for another waiver 6 months after the expiration of the last waiver RHCs that do not meet this requirement and do not request a waiver would be decertified
7	2. Must Employ One or More NP or PA “Employ” – usually evidenced by the employer’s provision of a W-2 form to the employee Must employ an NP or PA at all times The NP or PA would not be required to be a full time employee
8	2. Must Employ One or More NP or PA Regulation prohibiting RHCs from contracting with non-physician providers would be removed RHC would be allowed to contract with non-physician providers as long as at least 1 NP or PA is employed
9	Questions? Questions on RHC Staffing Requirements, Waivers, or Contracting?
10	II. Payment Issues Exceptions to the Payment Limit Payment Methodology Commingling Payment for High Cost Drugs
11	Exceptions to the Payment Limit Available to RHCs that are an integral and subordinate part of a hospital with less than 50 beds determined by either of 2 methods: Bed count as described in 412.105(b) or For sole community hospitals, the average daily census does not exceed 40 and the hospital in a RUCA 9 or 10
12	Rural Urban Commuting Areas (RUCA) Proposes to use RUCAs instead of UICs (Urban Influence Codes) More precise measurement of rurality Consistent with other CMS programs (e.g. hospital and ambulance payment systems) - More RHCs should be eligible for the exception to the payment limit
13	Payment Methodology 1833(a)(3)of the SSA, as amended by the MMA, states that (except for pneumoccocal and influenza vaccine and their administration), Medicare payment cannot exceed 80 percent of reasonable costs 1866(a)(2)(A)(ii) states that coinsurance cannot exceed 20 percent of reasonable charges
14	Payment Methodology Current: Medicare pays RHCs 80% of reasonable costs Proposed: Medicare pays RHCs reasonable costs minus coinsurance and deductible (based on facility charges), not to exceed 80 percent of reasonable costs
15	Examples RHCs with per-visit payment limit RHCs with exception to the payment limit
16	Ex. 1a - RHC With Per-Visit Payment Limit Upper payment limit= $75.63 Clinic charges $100 Current Method Medicare payment = $60.50 (80% of $75.63) Patient obligation = $20 (20% of $100) Clinic revenue = $80.50 ($60.50 + $20) Proposed Method Medicare payment = $55.63 ($75.63 - $20) Patient obligation = $20 (20% of $100) Clinic revenue = $75.63 (2008 per visit limit)
17	Ex. 1b - RHC With Exception to the Per-Visit Payment Limit Clinic’s Allowable Cost Per Visit (prior to application of beneficiary obligation) = $80 Clinic charges $100 Current Method Medicare payment = $64 (80% of $80) Patient obligation = $20 (20% of $100) Clinic revenue = $84 ($64 + $20) Proposed Method Medicare payment = $60 ($80 - $20) Patient obligation = $20 (20% of $100) Clinic revenue = $80 ($60 + $20)
18	Ex. 2a - RHC With Per-Visit Payment Limit Upper payment limit= $75.63 Clinic charges $80 Current Method Medicare payment = $60.50 (80% of $75.63) Patient Obligation = $16 (20% of $80) Clinic revenue = $76.50 ($60.50 + $16) Proposed Method Medicare payment = $59.63 ($75.63 - $16) Patient obligation = $16 (20% of $80) Clinic revenue = $75.63 (2008 per visit limit)
19	Ex. 2b -RHC With Exception to the Per-Visit Payment Limit Clinic’s Allowable Cost Per Visit (prior to application of beneficiary obligation) = $80 Clinic charges $80 Current Method Medicare payment = $64 (80% of $80) Patient obligation = $16 (20% of $80) Clinic revenue =$80 ($64 + $16) Proposed Method Medicare payment = $64 ($80 - $16) Patient obligation = $16 (20% of $80) Clinic revenue = $80 ($64 + $16)
20	Ex. 3a - RHC With Per-Visit Payment Limit Upper payment limit= $75.63 Clinic charges $70 Current Method Medicare payment = $60.50 (80% of 75.63) Patient obligation = $14 (20% of $70) Clinic revenue = $74.50 ($60.50 + $14) Proposed Method Medicare payment = $60.50 (80% of 75.63) Patient obligation = $14 (20% of $70) Clinic revenue = $74.50 (2008 per visit limit)
21	Ex. 3b - RHC With Exception to the Per-Visit Payment Limit Clinic’s Allowable Cost Per Visit (prior to application of beneficiary obligation) = $80 Clinic charges $70 Current Method Medicare payment = $64 (80% of $80) Patient obligation = $14 (20% of $70) Clinic revenue =$78 ($64 + $14) Proposed Method Medicare payment = $64* ($80 – $14 = $66 – $2) Patient obligation = $14 (20% of $70) Clinic revenue = $78 ($64 + $14) *$80 -$14 = $66, which would exceed 80% of the allowable cost
22	Commingling The sharing of RHC space, staff (employees or contractors), supplies, records, and other resources with an onsite Medicare Part B or Medicaid fee-for-service practice operated by the same RHC practitioners (physician or non-physician)
23	Conditions When Commingling Is Prohibited It results in duplicate Medicare or Medicaid reimbursement, either due to the inability of the RHC to distinguish its actual costs from those that are reimbursed on a fee for service basis, or for any other reasons The RHC and a Medicare fee-for-service practice operate simultaneously to select patient encounters for enhanced reimbursement
24	Conditions When Commingling May be Allowed The RHC shares some resources with a non-RHC entity (e.g. a multipurpose clinic) and maintains accurate records to assure that the RHC costs are only for those resources used for RHC purposes The RHC shares its practitioners with the ER of the hospital in an emergency or provides on-call services for an ER and continues to meet the conditions for certification and allocates appropriately the practitioner’s salary between RHC and non-RHC time
25	Commingling Questions Contact your MAC, FI, Carrier, or RO to Determine permissible resource-sharing situations Determine proper cost reporting methods
26	High Cost Drugs RHC reimbursement includes the cost of drugs provided incident to a patient visit High cost drugs (e.g. cancer treatments) may pose a financial risk Soliciting comments with possible solutions that are consistent with legislative requirements, commingling policies, and administrative accountability
27	Questions? Questions on Payment Requirements?
28	Additional Resources CMS Rural ODF July 29, 2008 2-3 pm EST CMS Special RHC ODF August 5, 2008 2-4 pm EST
29	CMS Regional RH Coordinators Region I – George Kazanjian (617) 565-1282 Region II – Frank Lifrieri (212) 616-2519 Region III - Patrick Hamilton (215)-861-4097 Region IV – Lana Dennis (404) 562-7379 Region V – Christine Davidson (312) 886-3642 Region VI – Beck Peal-Sconce (214) 767-6444 Region VII – Robert Epps (816) 426-6538 Region VIII – Lyla Nichols 303-844-6218 Region IX – Neal Logue (415) 744-3551 Region X – Alma Hardy (206) 615-2387
30	RHC Final Rule Comment period closes 5:00 p.m. on August 26, 2008 All comments will be considered and addressed in the Final Rule Provisions of the Final Rule will be effective 60 days after publication of the Final Rule, unless otherwise noted
31	"Thank You" Thank You! Corinne Axelrod