Some Federally Qualified Health Centers
(FQHCs) and Rural Health Clinics (RHCs)
have informed the Health Resources and
Services Administration (HRSA) that they
have had difficulty receiving reimbursement
from State Medicaid Agencies (SMAs) for
the provision of behavioral health services.
This has the potential of affecting the
health and overall well-being of FQHC
and RHC patients.
In response, the HRSA Administrator requested
clarification from the Centers for Medicare
& Medicaid Services (CMS) regarding
the statutory requirements pertaining
to Medicaid reimbursement to FQHCs and
RHCs for behavioral health services. CMS
responded by issuing a memo indicating
that SMAs are required to reimburse FQHCs
and RHCs for behavioral health services
provided by physicians, physicians assistants,
nurse practitioners, clinical psychologists,
and clinical social workers. (See attachment)
Section 1861(aa) of the Social Security
Act defines FQHCs/RHCs and the core services
provided by them. These services include
those provided by a physician, physician
assistant, nurse practitioner, clinical
psychologist, and clinical social worker.
(See § 1861(aa)(3)(A) and
§ 1861 (aa)(1)(A)-(B).) As stated in
the attached memo from the Director, Center
for Medicaid & State Operations, SMAs
are required to reimburse FQHCs and RHCs
for behavioral health services provided
by those practitioners named above whether
or not those services are included in
the State Medicaid plan[1].
The CMS memo further clarifies that the
requirement to reimburse FQHCs and RHCs
for behavioral health services furnished
by these same practitioners applies to
categorically eligible Medicaid beneficiaries.
Additionally, an SMA is required to reimburse
FQHCs and RHCs for behavioral health services
furnished by those same practitioners
to individuals who are eligible as medically
needy if the SMA has elected to provide
FQHC and RHC services to its medically
needy population. An SMA may choose not
to include reimbursement for certain services
to its optional medically needy population.
The requirement for Medicaid reimbursement
for FQHC and RHC services applies regardless
of whether the services are provided under
a fee-for-service arrangement or managed
care arrangement.
It is important to emphasize that in
order for FQHCs and RHCs to be reimbursed
by the SMA for behavioral health services,
FQHC/RHCs providers must be practicing
within the scope of their practice under
the state law.
Because access to mental health and substance
abuse services (MH/SA) is critical to
ensuring the health and overall well-being
of underserved and vulnerable populations
served by FQHCs, FQHCs are strongly encouraged
to work with their SMA and their State
Primary Care Association to address this
reimbursement issue. FQHCs that have questions
about this notice should contact their
Project Officer.
There are concerns that Federally Qualified
Health Centers (FQHCs) and Rural Health
Clinics (RHCs) are experiencing difficulty
obtaining Medicaid payments for their
behavioral health services furnished by
clinical psychologists, clinical social
workers, and nurse practitioners. You
ask for the Centers for Medicare &
Medicaid Services' agreement that services
furnished by these practitioners in FQHCs
and RHCs are required to be reimbursed
by state Medicaid agencies regardless
of whether the services are otherwise
included in the Medicaid state plan. While
there are certain services, the ones you
ask about included, for which state Medicaid
programs are indeed required to reimburse
FQHCs and RHCs, I emphasize that there
are also statutorily defined limits to
these requirements. Congress clearly did
not intend that any service, without qualification,
that is provided by an FQHC or RHC must
be paid for by a state's Medicaid program.
More detail on the requirements and limitations
is below, and your specific reimbursement
question is also addressed.
Congress specifically limited Medicaid
reimbursement for services in FQHCs and
RHCs under the Social Security Act. The
definition of FQHC services is the same
for Medicaid as it is for the Medicare
program. These services are defined, in
part, as those provided by a physician,
a physician assistant or nurse practitioner,
a clinical psychologist or clinical social
worker, and such services and supplies
furnished that are incidental to the services.
Moreover, the law requires that Medicaid
will pay for any other ambulatory services
in these settings, but in this case limited
the requirement to those other ambulatory
services that are also included in the
state Medicaid plan.
With respect to behavioral health services
furnished by clinical psychologists, clinical
social workers, and nurse practitioners,
Medicaid will provide for payments to
FQHCs and RHCS for services furnished
by these types of FQHCs/RHCs practitioners
to individuals who are categorically eligible
for Medicaid, or who are eligible as medically
needy (if a state Medicaid program has
elected to provide FQHCs and RHCs services
to its medically needy population).
Neither the Medicaid nor the Medicare
statute or regulations specifies the particular
services these three types of practitioners
may furnish. Our requirements are generally
limited to the practitioner meeting certain
educational and licensure conditions.
Therefore, as long as these FQHCs/RHCs
practitioners are practicing within the
scope of their practice under state law,
the FQHCs or RHCs payment should reflect
the services furnished to Medicaid eligible
beneficiaries by these types of practitioners.
[1] Medicaid will reimburse
for other ambulatory services provided
by FQHCs and RHCs that are included in
the State Medicaid plan.
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