048-37 Wyo. Code R. §§ 37-7 - Medicaid Allowable Payment for Services Furnished on or After January 1, 2001

(a) The Department shall reimburse for covered services provided to clients in a FQHC or RHC using a prospective payment rate determined pursuant to this Chapter.

(b) The Department shall establish a separate payment rate for each FQHC and RHC. The rate shall be determined using the base period Medicaid allowable costs, which are calculated as follows:

(i) The Department shall calculate a per visit cost for each FQHC and RHC for the FQHC's and RHC's 1999 and 2000 fiscal years. A fiscal year shall be the twelve (12) month period used by a FQHC or RHC for accounting and tax purposes.

(ii) The Medicaid baseline rate (rate established using the base period for each FQHC and RHC) with 1999 and 2000 fiscal year data shall be determined by calculating a per visit rate (total allowable costs divided by total patient visits) for fiscal years 1999 and 2000; adding the two (2) rates together; and dividing the sum by two (2).

(iii) The Medicaid baseline rate for each FQHC and RHC with only 2000 fiscal year data shall be determined by calculating a per visit rate (total allowable costs divided by total patient visits) for fiscal year 2000.

(iv) Scope of service changes for baseline rate.

(A) An FQHC or RHC which desires an adjustment to its baseline rate due to an increase or decrease in its scope of service shall:

(I) Notify the Department, in writing, of the increase or decrease; and

(II) Submit a settled Medicare Cost Report which documents the change in services and substantiates the costs associated with that change.

(B) The Department shall assess the information provided and shall determine if a rate change is warranted and the amount of any such change. Those determinations shall be based upon:

(I) The nature of the new or discontinued service regarding the type, intensity, duration, and amount of services. A change in the cost of a service is not considered in and of itself a change in the scope of services; and

(II) The reasonableness of the FQHC's or RHC's costs.

(C) The Department may request that the FQHC or RHC provide additional information to document the change in service. The information shall be provided before the Department is obligated to consider the FQHC's or RHC's request.

(v) The per visit rate calculated pursuant to this Section, as adjusted for changes in scope of service pursuant to this Section, shall be the FQHC's or RHC's baseline rate for services provided on or after January 1, 2001, and shall be the basis for future rate determinations.

(vi) For any FQHC or RHC that was not in operation during 1999 or 2000 fiscal years, refer to Section 7.

(c) The Department shall base all cost and rate calculations on a FQHC's or RHC's most recently settled Medicare Cost Report. If a settled Medicare Cost Report is not available, the Department shall use the FQHC's or RHC's Medicare Cost Report as filed.

(i) If a cost or rate calculation is based on an "as filed" Medicare Cost Report, the Department shall recalculate the cost or rate within a reasonable time after the FQHC's or RHC's settled cost report becomes available. If the cost or rate based on an "as filed" cost report is different from the cost or rate calculation based on the settled cost report, the Department shall only adjust the rate prospectively and shall not retroactively reimburse the FQHC or RHC for any underpayment or recover any overpayment.

(ii) A change in a FQHC's or RHC's rate pursuant to this subsection shall not affect any averages.

(d) The Department shall re-determine each provider's Medicaid allowable payment each Federal fiscal year beginning on or after October 1, 2001, as follows:

(i) The provider's Medicaid allowable payment in effect on October 1 of each year shall be adjusted by the percentage increase in the MEI as calculated using the annual data published in the fourth (4th) calendar quarter in the Federal Register or posted at the CMS Health Care Indicators website at https://www.cms.gov on the Market Basket Data updates page.

(ii) The provider's Medicaid allowable payment shall be adjusted prospectively to reflect any increase or decrease in the scope of services furnished by the FQHC or RHC during the FQHC's or RHC's fiscal year. The provisions of Section (b)(iv) shall apply to any proposed rate changes based on a change in services.

(iii) The payment established pursuant to Section 7(d) of this Chapter shall be effective for the calendar year beginning January 1 following the determination of the new rate.

Notes

048-37 Wyo. Code R. §§ 37-7

Amended, Eff. 1/6/2015. Amended, Eff. 9/6/2018. Amended, Eff. 8/11/2023.