PURPOSE: This amendment deletes or clarifies outdated
terms, language, and provisions regarding Provider-Based Rural Health
Clinics.
(1) General
Principles.
(A) The MO HealthNet program shall
reimburse Provider-Based Rural Health Clinics (PBRHC) based on the reasonable
cost incurred by the PBRHC to provide covered services, within program
limitations, related to the care of MO HealthNet participants less any
copayment or other third party liability amounts that may be due from the MO
HealthNet-eligible individual.
(B)
Reasonable costs shall be determined by the division based on a review of the
applicable cost reports. Reasonable costs shall not exceed the Medicare cost
principles set forth in 42 Code of Federal Regulations (CFR) parts 405 and 413.
(C) The Medicaid charges used to
determine the cost, and the payments used to determine the final settlement,
will be the charges and payments extracted from the Medicaid paid claims
history for reimbursable services paid on a percentage
basis.
(2) Definitions.
The following definitions shall apply for the purpose of this rule:
(A) "Audit" refers to the division's or its
authorized contractor's audit of a hospital's Medicaid cost report;
(B) Division. Unless otherwise designated,
"division" refers to the MO HealthNet Division, a division of the Department of
Social Services charged with the administration of the MO HealthNet
program;
(C) Cost-to-Charge Ratio
(CCR). The CCR is determined by dividing the PBRHC cost by the PBRHC charges
from the hospital's Medicaid Cost Report Worksheet C Part I.
(D) Fiscal Year (FY). The clinic's fiscal
reporting period that corresponds with the fiscal year of the hospital where
the clinic is based;
(E) PBRHC. A
clinic that is an integral part of a hospital, eligible for certification as a
Medicare rural health clinic in accordance with 42 CFR
405 and
491, and
operates with other departments of a hospital;
(F) Generally Accepted Accounting Principles (GAAP).
Accounting conventions, rules, and procedures necessary to describe accepted
accounting practice at a particular time promulgated by the authoritative body
establishing those principles;
(H) Provider or facility. A PBRHC with a valid MO
HealthNet participation agreement in effect with the Department of Social
Services for the purpose of providing PBRHC services to MO HealthNet-eligible
participants; and
(I)
Incorporation by reference. This rule incorporates by reference the following:
4. The Rural Health
Clinic Manual is incorporated by reference and made a part of this rule as
published by the Department of Social Services, MO HealthNet Division, 615
Howerton Court, Jefferson City, MO 65109, at its website at
https://dssruletracker.mo.gov/dss-proposed-rules/welcome.action
, April 6, 2021. This rule does not incorporate any subsequent amendments or
additions.
(3)
Administrative Actions.
(A) Annual Cost
Report.
1. Each PBRHC shall be individually
listed on the hospital's Medicaid cost report.
2. Under no circumstances will the division accept
amended cost reports for final settlement determination or adjustment after the
date of the division's notification of the final settlement amount.
(B) Records.
1. Maintenance and availability of records.
A. A provider must keep records in accordance
with GAAP and maintain sufficient internal control and documentation to satisfy
audit requirements and other requirements of this regulation, including
reasonable requests by the division or its authorized contractor for additional
information.
B. Adequate
documentation for all line items on the cost report shall be maintained by a
provider. Upon request, all original documentation and records must be made
available for review by the division or its authorized contractor.
C. Records of related organizations, as
defined by
42 CFR
413.17, must be available upon
demand.
D. Each facility shall
retain all financial information, data, and records relating to the operation
and reimbursement of the facility for a period of not less than five (5)
years.
(4) Non-allowable Costs. Cost not related to PBRHC
services shall not be included in a provider's costs. Nonallowable cost areas
include, but are not limited to, the following:
(A) Federal Reimbursement Allowance (FRA)
Tax;
(B) Bad debts, charity, and
courtesy allowances;
(C) Return on
equity capital;
(D) Capital cost
increases due solely to changes in ownership;
(E) Amortization on intangible assets, such as
goodwill, leasehold rights, covenants, but excluding organizational
costs;
(F) Attorney fees related
to litigation involving state, local, or federal governmental entities and
attorneys' fees that are not related to the provision of PBRHC services, such
as litigation related to disputes between or among owners, operators, or
administrators;
(G) Central office
or pooled costs not attributable to the efficient and economical operation of
the facility;
(H) Costs such as
legal fees, accounting costs, administration costs, travel costs, and the costs
of feasibility studies that are attributable to the negotiation or settlement
of the sale or purchase of any capital asset by acquisition or merger for which
any payment has been previously made under the program;
(I) Late charges and penalties;
(J) Finder's fees;
(K) Fund-raising expenses;
(L) Interest expense on intangible assets;
(M) Religious items or supplies or services
of a primarily religious nature performed by priests, rabbis, ministers, or
other similar types of professionals. Costs associated with portions of the
physical plant used primarily for religious functions are also
nonallowable;
(N) Research
costs;
(O) Salaries, wages, or
fees paid to non-working officers, employees, or consultants;
(P) Value of services (imputed or actual)
rendered by nonpaid workers or volunteers; and
(Q) Costs of services performed in a satellite clinic,
which does not have a valid MO HealthNet participation agreement with the
Department of Social Services for the purpose of providing PBRHC services to MO
HealthNet-eligible participants.
(5) Fee-for-Service (FFS) Claims Payments.
(A) Effective for dates of service beginning
July 1 of each year, PBRHC services that are an integral part of the hospital,
unless otherwise limited by regulation, shall be reimbursed by MO HealthNet,
based on the clinic's usual and customary charges multiplied by the lower of
one hundred percent (100%) or one hundred percent (100%) of the PBRHC's
cost-to-charge ratio as determined from the third prior year audited Medicaid
cost report. These payments shall be reduced by copayments and other third
party liabilities.
(6)
Interim Managed Care Payments.
(A) A PBRHC in
a MO HealthNet managed care region may request an interim payment, on forms
provided by the division, prior to the final settlement calculation. This
payment is limited to the ten percent (10%) not reimbursed by the managed care
health plans for covered services rendered to MO HealthNet managed care
participants during the reporting period. The interim payment shall occur on a
quarterly basis.
(7)
Final Settlement Calculations.
(A) For cost
reports with a FY ending in 2021 and forward, the final settlement is
calculated as follows:
1. The audited Medicaid
cost report that includes each PBRHC's fiscal year shall be used to calculate
the final settlement, in order that the PBRHC's net reimbursement shall equal
reasonable costs as described in this section;
2. Fee-for-Service Section.
A. The division takes the PBRHC's allowable
Medicaid charges from services paid on a percentage basis multiplied by the
PBRHC's cost-to-charge ratio to determine the PBRHC's cost. From this cost, the
PBRHC claims payments are subtracted. The difference is either an overpayment
or an underpayment;
3.
Managed Care Section.
A. The division uses
the PBRHC Form from the Medicaid Supplemental Packet, which is filed with the
hospital cost report, and associated detail for the PBRHC facility to determine
charges. These charges are multiplied by the PBRHC's cost-to-charge ratio to
determine the PBRHC's cost. From this cost, the PBRHC payments associated with
above charges are subtracted. If applicable then subtract any interim payments
paid prior to the final settlement. The difference is either an overpayment or
an underpayment; and
4.
Final Settlement Amount.
A. The division adds
together the overpayment or underpayment from the FFS Section and the Managed
Care Section and then subtracts any advanced settlement payments, if
applicable, to come up with a total overpayment or underpayment which will be
the final settlement amount.
(B) For cost reports with a FY ending in 2020
and prior, the final settlement is calculated as follows:
1. The audited Medicare Notice of Program
Reimbursement (NPR) cost report that includes each PBRHC's fiscal year shall be
used to calculate the final settlement, in order that the PBRHC's net
reimbursement shall equal reasonable costs as described in this section. The
provider shall provide the NPR upon request from the division;
2. Fee-for-Service Section.
A. The division takes the PBRHC's allowable
Medicaid charges from services billed under this rule multiplied by the PBRHC's
Medicare NPR cost-to-charge ratio to determine the PBRHC's cost. From this
cost, the PBRHC FFS claims payments are subtracted. The difference is either an
overpayment or an underpayment;
3. Managed Care Section.
A. The division uses the PBRHC Form from the
Medicaid Supplemental Packet, which is filed with the hospital cost report, and
associated detail for the PBRHC facility to determine charges. These charges
are multiplied by the PBRHC's cost-to-charge ratio to determine the PBRHC's
cost. From this cost, the PBRHC payments associated with above charges are
subtracted. If applicable then subtract any interim payments paid prior to the
final settlement. The difference is either an overpayment or an underpayment;
and
4. Final Settlement
Amount.
A. The division adds together the
overpayment or underpayment from the FFS Section and the Managed Care Section
and then subtracts any advanced settlement payments, if applicable, to come up
with a total overpayment or underpayment which will be the final settlement
amount.
(8) Reconciliation.
(A) The division shall send written notice to the
hospital, of which the PBRHC is an integral part, of the following:
1. Underpayments. If the total reimbursement
due the PBRHC exceeds the interim payments made for the reporting period, the
division makes a lump-sum payment to the PBRHC to bring total interim payments
into agreement with total reimbursement due to the PBRHC; and/or
2. Overpayments. If the total interim
payments made to the PBRHC for the reporting period exceed the total
reimbursement due from the PBRHC for the period, the division arranges with the
PBRHC for repayment through a lump-sum refund, or if that poses a hardship for
the PBRHC, through offset against subsequent interim payments or a combination
of offset and refund.
(9) Sanctions.
(A) The division may impose sanctions against
a provider in accordance with
13
CSR 70-3.030 Sanctions for False or Fraudulent Claims
for Title XIX Services or any other sanction authorized by state or federal law
or regulation.
(B) Overpayments due
the MO HealthNet program from a provider shall be recovered by the division in
accordance with
13
CSR 70-3.030 Sanctions for False or Fraudulent Claims
for Title XIX Services.
(10) Appeals. In accordance with sections
208.156
and
621.055,
RSMo, providers may seek hearing before the Administrative Hearing Commission
of final decisions of the director, Department of Social Services or the MO
HealthNet Division.
(11) Payment
Assurance.
The state will pay each PBRHC, which furnishes the services
in accordance with the requirements of the state plan, the amount determined
for services furnished by the PBRHC according to the standards and methods set
forth in the regulations implementing the PBRHC Reimbursement Program.