ISSUE
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TABLES AFFECTED
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Contracted Care
(Specialty, dental,
mental health,
etc.)
(Service must
be paid for by grantee!)
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5
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Providers (Column A) are counted if the contract is
for a portion of an FTE (e.g., one day a week OB = 0.20 FTE). Providers are not
counted if contract is for a service (e.g., $X per visit or $55 per
RBRVU). Encounters (Column B) are always counted, regardless
of method of provider payment or location of service (grantee’s site or
contract provider’s office.)
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6
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Grantee receives encounter form or equivalent from
contract provider, counts primary diagnosis and/or services provided as
applicable.
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8A
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Column A: Net Cost. Cost of provider/service
is reported on applicable line.
Column B: Overhead. Grantee will generally
use a lower “overhead rate” for off-site services.
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9D
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Charge (Column A) is grantee’s UCR charge if
on-site; as contractor’s UCR charge if off site.
Collection (Column B) is the amount received by either
grantee or contractor from first or third parties.
Allowance (column D) is amount disallowed by a
third party for the charge (if on lines 1 – 12)
Sliding Discount (column E) is amount written off
if the patient is uninsured (line 13). Calculated as UCR charge minus amount
collected from patient, minus amount owed by patient as their share of
payment.
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Services
provided by a volunteer provider (Service are not paid for by
grantee!)
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5
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Providers (Column A) are counted if the service is
provided on site at grantees clinic. Hours volunteered are used to calculate
FTE as with any other part time provider. Providers are not counted
if their services are provided at their own offices.
Encounters (Column B) are counted only if the
service is provided at the site in the contractors scope of service and under
the grantee’s control.
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6
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Grantee counts primary diagnosis and/or services provided
on site, as applicable.
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9D
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If on-site, treated exactly the same as for staff. Do not
include if off-site.
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WIC
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Cover Sheets
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3A, 3B, 4
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Clients whose only contact with the grantee is for WIC
services and who do not receive another form of service counted on Table 5
from providers outside of the WIC program are not counted as patients
on any of these tables. Do not count as patients because of health
education or enabling services provided by WIC.
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5
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Staff (Column A) are counted on line 29a.
Encounters and patients (Columns B and C) are never
reported unless otherwise justified.
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8A
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Column A: Net costs. Total cost of program
reported in column a.
Column B: Overhead. Since much of the
administrative cost of the program will be included in the direct costs, it
is presumed that overhead will be at a significantly lower rate.
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9D
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Nothing associated with the WIC program is to be reported
on this table.
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9E
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Income for WIC programs, though originally federal, comes
to grantees from the State. Unless the grantee is a state
government, the grant/contract funds received are reported on line 6.
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In-house
pharmacy or dispensary services for grantee’s patients [see below for
other situations].
(including only
that part of pharmacy that is paid for by the grantee and dispensed by
in-house staff.)
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5
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Column A: Staff. Pharmacy staff are normally
reported on line 23. To the extent that the pharmacy staff have an
incidental responsibility to provide assistance in enrolling patients in
Pharmaceutical Assistance Programs, they are included on line 23. Staff
(generally not including pharmacists) who spend a readily identifiable
portion of their time with PAP programs should be counted on line 28, the
“other enabling” line.
Column B: Encounters. The UDS does not
require the counting or reporting of encounters with pharmacy whether it is
for filling prescriptions or associated education or other patient / provider
support.
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8A
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Line 8b, Column A: Pharmaceutical Direct Costs. The
actual cost of drugs purchased by the pharmacy is placed on line 8b. (The
value of donated drugs (generally calculated at 340(b) rates) is reported on
line 18 in column c.)
Line 8a, column A: Other Pharmacy Direct Costs. All
other operating costs of the pharmacy are shown on line 8a. Include
salaries, benefits, pharmacy computers, supplies, etc.
Line 11, column A: Enabling Direct Costs. Show
the staff and other costs of staff (full- time, part-time or allocated time)
spent assisting patients to become eligible for PAPs.
Column B: Facility and Administration. All
overhead costs associated with line 8a and 8b are reported on line 8a. While
there may be some overhead cost associated with the actual purchase of the
drugs, these costs are generally minimal when compared to the total cost of
the drugs.
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8B
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Line 11: Eligibility Services. The cost of
helping gain eligibility for PAPs is shown on line 11.
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9D
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Charge (Column A) is grantee’s full retail charge
for the drugs dispensed.
Collection (Column B) is the amount received from
patients or insurance companies.
Allowance (column D) is amount disallowed by a
third party for the charge (if on lines 1 – 12)
Sliding Discount (column E) is amount written off
if the patient is uninsured (line 13). Calculated as retail charge minus
amount collected from patient, minus amount owed by patient as their share of
payment.
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9E
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The value of donated drugs is not
reported on this table – it is reported on Table 8A. (See above)
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In-house
pharmacy for community
(i.e., for
non-patients)
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description
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Many CHCs which own licensed pharmacies which also provide
services to members of the community at large who are not CHC
patients. Careful records are required to be kept at these pharmacies to
ensure that drugs purchased under section 340(b) provisions are not dispensed
to patients. Some of these pharmacies are totally in-scope, while others
have their “public” portion out of scope. If the public aspect is “out of
scope”, none of its activities are reported on the UDS. If it is in scope,
the public portion should be considered an “other activity” and treated as
follows:
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5
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Column A: Staff. Report allocated public
portion of staff on line 29a: Other Programs and Services.
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8A
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Report all related costs, including cost of
pharmaceuticals, on line 12: Other Related Services.
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9E
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Report all income from public pharmacy on line 10: Other,
and specify that it is from “Public Pharmacy.”
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Contract
Pharmacy
Dispensing to
clinic patients, generally using 340(b) purchased drugs
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5
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8A
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If the pharmacy is charging one amount for “managing” the
program and/or an amount for “dispensing” the drugs; and another amount for
the drugs themselves, the former charge is reported on line 8a, the latter on
line 8b.
If the CHC is purchasing the drugs directly [because of
340(b) regulations] the amount it spends on purchasing goes on line 8b, and
any administrative or dispensing costs charged by the pharmacy go on line 8a.
If the pharmacy is reporting a flat amount for services
including both pharmaceuticals and their services, and there is no
reasonable way to separate the amounts report all costs on line 8b.
Associated administrative costs will go on line 8a in column B, even though
line 8a column A is blank.
If prepackaged drugs are being purchased, and there is
no reasonable way to separate the pharmaceutical costs from the dispensing /
administrative costs report all costs on line 8b. Associated
administrative costs will go on line 8a in column B, even though line 8a
column A is blank.
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9D
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Charge (Column A) is grantee’s full retail charge
for the drugs dispensed or the amount charged by the pharmacy / pre-packager
if retail is not known.
Collection (Column B) is the amount received from
patients or insurance companies or, under certain circumstances, the
pharmacy. (Note: most CHCs have this arrangement only for their uninsured
patients.)
Allowance (column D) is amount disallowed by a
third party for the charge (if on lines 1 – 12)
Sliding Discount (column E) is amount written off
if the patient is uninsured (line 13). Calculated as retail charge (or
pharmacy charge) minus amount collected from patient (by pharmacy or CHC),
minus amount owed by patient as their share of payment.
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9E
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No income would be reported on Table 9E.
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Donated Drugs
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8A
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If the drugs are donated to the CHC and then dispensed
to patients show their value [generally calculated at 340(b) rates] on
line 18, column C. If the drugs are donated directly to the patient
no accounting for the value of the drugs is made in the UDS, even if the CHC
receives and holds the drugs for the patient.
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9D
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If a dispensing fee is charged to the patient, show this
amount (only) and its collection / write-off.
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9E
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Do not show any amount, even though GAAP might suggest
another treatment for the value.
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Clinical
dispensing of drugs
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description
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Many pharmaceuticals, ranging from vaccines to allergy
shots to family planning shots or pills, are dispensed in the clinic area of
the CHC. This dispensing is considered to be a service attendant to the
visit where it was ordered or, in the case of vaccinations, to be a community
service. In most instances it is appropriate to charge for these services,
though they are not considered to be encounters.
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3A/3B/4
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If this is the only service the individual has received
during the year, they are not counted as patients.
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5
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These services are not counted as separate visits.
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6
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Because these are not visits, they are not counted on
Table 6.
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8A
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Costs are reported on line 8b – pharmaceuticals. In the
case of vaccines obtained at no cost through the Vaccines For Children
program, the value may be reported on line 18 – donated services and
supplies.
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9D
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Full charges, collections, allowances and discounts are
reported as appropriate. Note that it is not appropriate to
charge for a pharmaceutical that has been donated, though an administration
and/or dispensing fee is appropriate. Note that Medicare has separate
flu vaccine rules.
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9E
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Do not show any amount, even though GAAP might suggest
another treatment for the value.
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Adult Day Health
Care (ADHC)
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description
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ADHC programs are recognized by Medicare, Medicaid and
certain other third party payors. They involve caring for an infirm, frail
elderly patient during the day to permit family members to work, and to avoid
the institutionalization of and preserve the health of the patient. They are
quite expensive and may involve extraordinary PMPM capitation payments,
though are thought to be cost effective compared to institutionalization. If
patients are covered by both Medicare and Medicaid treat as in Medi-Medi,
below.
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5
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When a provider does a formal, separately billable,
examination of a patient at the ADHC facility, it is treated as any other
medical visit. The nursing, observation, monitoring, and dispensing of
medication services which are bundled together to form an ADHC service are not
counted as a visit for the purposes of reporting on this table.
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9D
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ADHC charges and collections are reported. Because of
Medicaid FQHC procedures it is possible that there will also be significant
positive or negative allowances. See also Medi-Medi below.
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Medi-Medi
Cross-Over
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description
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Some individuals are eligible for both Medicare and
Medicaid coverage. In this case, Medicare is primary and billed first.
After Medicare pays its (usually FQHC) fee, the remainder is billed to
Medicaid which pays the difference between its FQHC rate and what Medicare
paid.
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4
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Patients are reported on line 9, Medicare. Do not
report as Medicaid!
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9D
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While initially the entire charge shows as a Medicare
charge, after Medicare makes its payment, the remaining amount is
re-classified to Medicaid. This means that eventually the charges and
collections will be the same, though for any given twelve month period the
cash positions will probably not net out. In most cases a large portion of
the total charge will transfer to Medicaid where it will be received and/or
written off as an allowance.
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Certain grant
supported clinical care programs: BCCCP, Title X, , etc.
(These are
fee-for service or fee-per-visit programs only.)
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description
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Some programs pay providers on a fee-for-service or
fee-per visit basis under a contract which may or may not also have a cap on
total payments per year. They cover a very narrow range of services. Breast
and Cervical Cancer Control and Family Planning programs are the most common,
but there are others.
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4
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These are not insurance programs. They pay for a
service, but the patient is to be classified according to their primary
health insurance carrier. Most of these programs do not serve insured
patients, so most of the patients are reported on line 7 as uninsured.
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9D
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While the patient is uninsured, there is an “other
public” payor for the service. The clinic’s usual and customary charge for
the service is reported on line 7 in column A, and the payment is reported in
column B. Since the payment will almost always be different than the charge,
the difference is shown as an allowance in column D.
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9E
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The grant or contract is not shown on Table 9E. It
is fully accounted for on Table 9D.
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State or local
safety net programs
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description
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These are programs which pay for a wide range of clinical
services for uninsured patients, generally those under some income limit set
by the program. They may pay based on a negotiated fee-for-service, or
fee-per-visit. They may also pay “cents on the dollar” based on a cost
report, in which case they are generally referred to as an “uncompensated
care” program.
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4
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While patients may need to qualify for eligibility, these
programs are not considered to be public insurance. Patients served are
almost always to be counted on line 7 as uninsured.
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9D
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The charges are to be considered charges directly to the
patient (reported on line 13, column A). If the patient pays any co-payment,
it is reported in column B. If they are responsible for a co-payment but do
not pay it, it remains a receivable until it collected or is written off as a
bad-debt in column f. All the rest of the charge (or all of the charge if
there is no co-payment) is reported as a sliding discount in Column E.
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9E
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The total amount received during the calendar year is
reported on line 6a.
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Workers
Compensation
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4
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Workers Compensation is a form of liability insurance
for employers, not a health insurance for employees. Patient’s
whose bills are being paid by Workers Compensation should have a related
insurance that is what is reported on Table 4 (even if it is not being billed
or cannot be billed by the CHC.) In general, if they had an employer paid /
work-place based health insurance plan they would be reported on line 11. If
they do not have any health insurance, they are reported on line 7.
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9D
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Charges, collections and allowances for Workers
Compensation covered services are reported on line 10.
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Tricare, Trigon,
Veterans Administration, Public Employees Insurance, etc.
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4
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While there are many individuals whose insurance premium
is paid for by a government, ranging from military and dependents to school
teachers to congressmen and HRSA staff, these are all considered to be
private insurances. They are reported on line 11, not on line 10a.
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9D
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Charges, collections and allowances are reported on lines
10 – 12, not on lines 7 – 9.
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Contract sites
(In-scope
sites in schools, workplaces, jails, etc.)
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description
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Some CHCs have included in their scope of service a site
in a school a workplace, a jail, or some other location where they are
contracted to provide services to (students / employees / inmates / etc.) at
a flat rate per session or other similar rate which is not based on the
volume of work performed. The agreement generally stipulates whether and
under what circumstances the clinic may bill third parties.
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4
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Lines 1-6 – income: In general, income should
be obtained from the patients. In prisons, it may be assumed that all are
below poverty (line 1). In schools, income should be that of the parent or
unknown or, in the case of minor consent services, below poverty. In the
workplace, income is the patient’s family income or, if not known, “unknown”
(Line 5).
Lines 7-12 – insurance: Record the actual form
of insurance the patient has. Do not consider the agency with whom the
clinic is contracted to be an insurer. (Schools and jails are not “other
public” insurance.)
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5
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Count all encounters as appropriate. Do not reduce or
reclassify FTEs for travel time.
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8A
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Costs will generally be considered as medical (lines 1-3)
unless other services (mental health, case management, etc) are being
provided. Do not report on line 12—“other related services”
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9D
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Unless the encounter is being charged to a third party
such as Medicaid the clinic’s usual and customary charges will appear on
line 10, column A. The amount paid by the contractor is shown in column B.
The difference (positive or negative) is reported in column D.
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9E
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Contract revenue is not reported on Table 9E.
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S-CHIP
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4
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Medicaid: If S-CHIP is handled through
Medicaid and the enrollees are identifiable, they are reported on line 8b. If
it is not possible to differentiate S-CHIP from regular Medicaid, the
enrollees are reported on line 8a with all other Medicaid patients.
Non-Medicaid: S-CHIP enrollees in states which
do not use Medicaid are reported as “Other Public S-CHIP” on line 10b. Note
that, even if the plan is administered through a commercial insurance plan,
the enrollees are not reported on line 11.
For information about
the type of S-CHIP Program in your state: http://www.statehealthfacts.kff.org/cgi-bin/healthfacts.cgi?action=compare&category=Medicaid+%26+SCHIP&subcategory=SCHIP&topic=SCHIP+Program+Type
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9D
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Medicaid: Report on lines 1 – 3 as
appropriate.
Non-Medicaid: Report on lines 7 – 9 as
appropriate. Do not report on lines 10 – 12 even if the plan is
administered by a commercial insurance company.
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Carve-outs
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description
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Relevant to capitated managed care only. Grantee
has a capitated contract with an HMO which stipulates that one set of CPT
codes will be covered by the capitation regardless of how often the service
is accessed, and another set of codes which the HMO will pay for on a
fee-for-service basis whenever it is appropriate. Most common carve-outs
involve lab, radiology and pharmacy, but specific specialty care or diagnoses
(e.g., perinatal care) may also be carved out.
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9C
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Lines 1a/1b. The actual capitation received
from the HMO is reported on line 1a. The additional amounts received as a
result of the carve-outs are reported on line 1b.
Lines 5a/5b. The cost of delivering the
capitated services are reported on line 5a; the costs of delivering the
carved-out services are reported on 5b. The costs of the carved out services
are generally calculated based on the associated charges, but are
generally not just equal to those charges.
Lines 8a/8b, 10a/10b. Member months and
enrollees are counted only on the capitated lines (lines 8a and 10a)
Lines 9a/9b. The encounters for the capitated
patients are counted on line 9a. No encounters are reported for the carved
out services if the are a part of another encounter (e.g., the lab part) but
encounters are reported if the service (e.g. prenatal care or
HIV treatment) is carved out.
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9D
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Lines 2a/b, 5a/b, 8a/b, 11a/b. Capitation
payments are reported on the “a” lines, carve out payments are reported on
the “b” lines. The numbers will in general be the same as on Table 9C.
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(Migrant) Vouchers
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description
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Voucher Programs have traditionally been an
exclusive part of the Migrant and Seasonal Farmworker program, though in
recent years some Homeless and even CHC programs have made use of the
mechanism. In this system, the center identifies services that are needed by
its patients which cannot be provided by their in-house staff. Vouchers are
written to authorize a third party provider to deliver the services, and
voucher is returned to the grantee for payment. Payment is generally at less
than the providers full fee, but is consistent with other payors such as
Medicaid.
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3a, 3b, 4
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Patients are counted even if the only service that
they receive is a vouchered service, provided that these services would make
the patient eligible for inclusion if the Center provided them. Thus a
vouchered Taxi ride would not make the patient “countable” because
transportation services are not counted on Table 5.
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5
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Column A: There is no way to account for the
time of the voucher providers. As a result, zero FTEs are reported with regard
to these services. If there is a provider who works at the center,
the FTE of that provider is counted. For example, the
one-day-a-week family practitioner would be reported as 0.20 FTEs on line 1.
But the 125 vouchered visits to FPs would not result in an additional count
on line 1.
Column B: Count all visits that are paid for
by voucher. DO NOT count visits where the referral is to a provider who is
not paid in full for the service (i.e., a “voucher” to a doctor who donates
five visits per week does NOT generate a visit that is counted on Table 5.
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6
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Diagnoses / Services. The Voucher program is
expected to receive from the provider a bill similar to a HCFA-1500 which
lists the services and diagnoses. These are to be tracked by the center and
reported on Table 6.
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8a
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Cost of Vouchered Services. The costs are
reported on the appropriate line. Medical vouchers are reported on Line 1,
not Line 3. Report only those costs paid directly by the grantee.
Discounts. Virtually all clinical providers
are paid less than their full fee. Some grantees like to report the amount
of these discounts as “donated services”. While this is not required,
grantees may report the difference between the voucher provider’s full fee
and the contracted voucher payment as a donated service on line 18, column D.
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9d
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Column A: Charges. Report the full charge
that the provider shows on their HCFA-1500 as the charge on line 13 – self
pay. Do not use the voucher amount as the full charge.
Column B: Collections. If the patient paid
the voucher program a nominal or other fee, show this in column B.
Column E: Sliding Discounts. Show the
difference between the full charge and the amount that the patient was supposed
to pay in Column E. Do not show the full amount in Column E if the
patient was supposed to make a payment to the center and failed to do so.
Column F: Bad Debt. Show any amount (such as
a nominal fee) that the patient was supposed to pay but failed to pay. Bad
debts are recognized consistent with the center’s financial policies.
Amounts not paid may be considered a bad debt in 30 days or in a year –
whatever is the center’s policy.
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