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Slide 1: Review
of Final Rule
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Slide 2:
On September 22, 2006, CMS announced the
formal withdrawl of the RHC rules changes
published on December 23, 2003.
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Slide 3: Immediate Impact
Why was this Done?
What does it Mean?
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Slide 4: Questions raised by Withdrawal
What are the PA/NP/CNM Staffing requirements?
What happens to the QAPI initiative:
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Slide 5:
What happens with decertification?
Does this mean Commingling is permissible?
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Slide 6: Long-Term Actions
What changes can we expect?
When will those changes be announced?
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Slide 7: RHC Regulatory Change
Federal Register, December 24, 2003
CMS
issued a final rule December 03 relating to RHC's:
- Addressing BBA 97- changes.
- Mechanism for decertification of RHC's.
- Requiring QAPI Program review.
Effective February 23, 2004
- Withdrawn - enter date here
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Slide 8: The Rule
- Stipulates that all Rural Health Clinics must be located in "currently" designated shortage areas.
- Establishes a mechanism for RHCs that can no longer meet the location requirements to apply for an exception to this requirement and continue to participate in the RHC program. Limits waivers of non-physician provider staffing.
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Slide 9: The Rule (continued)
- Codifies the definition of a "bed" for purposes of the RHC cap exception for hospitals with fewer that 50 beds.
- Clarifies Medicare policy as it relates to commingling.
- Codifies the RHC payment limits previously extended to most provider-based RHCs.
- Codifies PA/NP/CNM staffing requirement at 50% of time clinic is open to see patients.
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Slide 10: The Rule (continued)
- Restricts PA/NP/CNM staffing waiver requests to already certified RHCs.
- Mandates the establishment of a Quality Assessment Performance Improvement initiative by RHCs.
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Slide 11: Commingling Defined
- Facilities may not be simultaneously operated as an RHC and a traditional fee-for-service Medicare practice. RHC practitioners who are "on the RHC clock" cannot bill Medicare Part B for covered services that would have otherwise been covered as RHC services. The key word here is simultaneous.
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Slide 12: Commingling
Defined
- Non-RHC practitioners may provide Medicare covered services
to Medicare beneficiaries within the four walls of the RHC.
The non-RHC practitioner may bill Medicare Part B for those
covered services. If a non-RHC practitioner provides these
services and bills Part B, proper care must be taken to
adjust the cost report with regard to administration and
overhead associated with this "shared space" to
prevent double billing.
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Slide 13: Commingling
Defined
- Specifically recognizes, CAH, PPS Rural Hospitals may
share staff however effective tracking and cost allocation
must occur.
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Slide 14: Hospital Bed Defined:
The rule codifies the definition of a hospital bed for purposes
of qualifying for Cap exception. Federal law mandates that
all RHCs are subject to the RHC per visit payment cap except
those operated by hospitals with fewer than 50 beds. A "counted
bed" is defined as:
- A hospital bed that is available (i.e. meets the definition
found in Sec. 412.105(b) of 42 CFR, Chapter IV); OR
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Slide 15: Hospital Bed Defined:
In the case of a hospital with more than 50 beds, that is
a sole community hospital as determined in accordance with
Sec. 412.92 or 412.109(a) of 42 CFR, Chapter IV, AND;
- Is located in a level 8 or level 9 non-metropolitan county using urban influence
codes as defined by the U.S. Department of Agriculture;
AND
- Has an average daily patient census that does not exceed 40.
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Slide 16: RHC Certification/Decertification
Exception Criteria
New facilities seeking RHC certification that are areas with
outdated shortage area designations cannot be certified as
RHCs. Existing RHCs that no longer meet the location criteria
may be decertified.
In order for a shortage area (HPSA, MUA or governor designated
area) to be considered current, the area must have been designated
and/or updated within the three year period prior to RHC certification
or recertification.
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Slide 17: RHC
Certification/Decertification
Exception Criteria
In order for a facility to retain its RHC certification,
despite no longer being located in a valid shortage area,
the RHC must demonstrate that it is an "essential provider".
The new rules identify four types of essential providers:
- Sole community provider,
- Major community provider,
- Specialty clinic, or
- Extremely rural community provider.
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Slide 18: Essential
Provider Defined:
- Sole Community Provider - The RHC is the only
participating primary care provider within 30 minutes travel
time. For purposes of this exception, a participating primary
care provider means an RHC, an FQHC, or a physician practicing
in either general practice, family practice, or general
internal medicine that is actively accepting and treating
Medicare beneficiaries and low-income patients (Medicaid
beneficiaries and the uninsured, regardless of their ability
to pay).
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Slide 19: Essential
Provider Defined:
- Major Community Provider - The RHC has Medicare
and low-income patient (Medicaid and uninsured) utilization
rates equal to or above 51% of low-income patient utilization
rates equal to or above 31 %. The RHC is also actively accepting
and treating a major share of Medicare, Medicaid, and uninsured
patients (regardless of their ability to pay) compared to
other participating RHCs that are within 30 minutes travel
time; or, if the clinic is the only participating RHC within
30 minutes travel, the RHC is actively accepting and treating
a major share of Medicare, Medicaid, and uninsured patients
(regardless of their ability to pay) compared to other participating
primary care providers.
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Slide 20: Essential
Provider Defined:
- Specialty Clinic - The RHC (located within 30
minutes travel time) is the sole or major source of pediatric
or OB/GYN services for Medicare (where applicable), Medicaid,
and uninsured patients (regardless of their ability to pay)
and is actively accepting and treating these patients. Only
clinics that exclusively provide pediatric or OB/GYN services
can receive an exception under this test. A specialty clinic
is also an RHC that is the sole source of mental health
services, as defined in Sec. 405.2450. For purposes of meeting
this test, mental health services must be furnished onsite
to clinic patients. Clinics applying as a major source of
pediatric or OB/GYN services must have low-income patient
(Medicaid and uninsured) utilization rates equal to or above
31%.
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Slide 21: Essential
Provider Defined:
- Extremely Rural Community Provider - The RHC is
actively accepting and treating Medicare, Medicaid, and
uninsured patients (regardless of their ability to pay)
and is located in a frontier county (less than six persons
per square mile) or in a level 8 or level 9 non-metropolitan
county using urban influence codes as defined by the U.S.
Department of Agriculture.
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Slide 22: Application of Part B
Co-Pay and Deductible
- The revised regulations clarify how an RHC must apply the deductible and co-insurance rules for the Medicare beneficiary.
- The deductible is the same as Medicare Part B. The patient will pay RHC charges up to the patient's unmet annual deductible.
- Medicare pays 80% of the RHC all-inclusive rate for the encounter. The patient is responsible for co-insurance equal to 20% of the charges for the encounter.
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Slide 23: Payment Rates Defined
- Provider-based and freestanding RHCs will be paid an all-inclusive Medicare visit rate based on the provider's costs, subject to an annual payment limit set by CMS.
- For provider-based clinics, when the RHC is part of a hospital with fewer than 50 beds, there is an exception to the annual payment limit.
- "Fewer than 50 beds" is defined as one of the following:
Fewer than 50 beds, or, all of the following:
- Sole community hospital
- Located in a level 8 or level 9 non-metropolitan county.
- Average daily census does not exceed 40.
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Slide 24: QAPI Program
- Must be appropriate to the complexity of the RHC operations,
data driven, and focused on improving outcomes
in patient safety, quality of care and patient
satisfaction.
- Must include objective measures for at least four organizational processes
and clinic utilization.
- For each of the organizational and clinical processes the RHC must develop performance measures and outcome measures and use the performance measures to track and analyze performance, set priorities for performance improvement efforts based on high-volume, high-risk services, chronic conditions, patient safety, and patient satisfaction, conduct distinct improvement projects.
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Slide 25: QAPI Program (continued)
- The number and complexity of projects will depend on the size and resources of the RHC, and document the QAPI projects.
- An information system designed to support the QAPI effort is suggested and will be considered a QAPI project.
- The professional staff, administration, and board are responsible for setting the scope and priorities of the QAPI program.
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