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Bill Finerfrock
Rural Health Clinics Technical Assistance Conference Call Presentation,
October 19, 2006

Review of Final Rule TOP


Slide 1: Review of Final Rule

Review of Final Rule TOP


Slide 2:

On September 22, 2006, CMS announced the
formal withdrawl of the RHC rules changes
published on December 23, 2003.

    Review of Final Rule TOP


    Slide 3: Immediate Impact

    Why was this Done?

    What does it Mean?

      Review of Final Rule TOP


      Slide 4: Questions raised by Withdrawal

      What are the PA/NP/CNM Staffing requirements?

      What happens to the QAPI initiative:

        Review of Final Rule TOP


        Slide 5:

        What happens with decertification?

        Does this mean Commingling is permissible?

        Review of Final Rule TOP


        Slide 6: Long-Term Actions

        What changes can we expect?

        When will those changes be announced?

        Review of Final Rule TOP


        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        • Withdrawn - enter date here
        Review of Final Rule TOP


        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.
        Review of Final Rule TOP


        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.
        Review of Final Rule TOP


        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.
        Review of Final Rule TOP


        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.
        Review of Final Rule TOP


        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.
        Review of Final Rule TOP


        Slide 13: Commingling Defined

        • Specifically recognizes, CAH, PPS Rural Hospitals may share staff however effective tracking and cost allocation must occur.
        Review of Final Rule TOP


        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
        Review of Final Rule TOP


        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.
        Review of Final Rule TOP


        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.

        Review of Final Rule TOP


        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:

        1. Sole community provider,
        2. Major community provider,
        3. Specialty clinic, or
        4. Extremely rural community provider.
        Review of Final Rule TOP


        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).
        Review of Final Rule TOP


        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.
        Review of Final Rule TOP


        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%.
        Review of Final Rule TOP


        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.
        Review of Final Rule TOP


        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.
        Review of Final Rule TOP


        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:
          1. Sole community hospital
          2. Located in a level 8 or level 9 non-metropolitan county.
          3. Average daily census does not exceed 40.
        Review of Final Rule TOP


        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.
        Review of Final Rule TOP


        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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