Current and Emerging Rural Issues in Medicare

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1 Current and Emerging Rural Issues in Medicare Captain Corinne Axelrod, MPH, L.Ac., Dipl.Ac. Senior Health Insurance Specialist Centers for Medicare and Medicaid Services Center for Medicare, Hospital and Ambulatory Policy Group AHLA Conference March 20, Rural Health Clinics (RHCs) Federally Qualified Health Center (FQHCs) Key components of the Nation s safety net system Providing access to primary care and preventive services to underserved people for >30 years 2 1

2 RHCs and FQHCs Approximately 3,800 RHCs Rural, underserved areas Approximately 1,200 FQHCs (8500 sites) Rural or urban, in or serving underserved areas Outpatient services typically furnished in a physician s office. 3 RHC and FQHC Reimbursement Paid an all-inclusive rate per-visit for qualified primary and preventive health services Rate determined based on reasonable costs for each RHC/FQHC by dividing allowable costs by the number of actual visits, subject to productivity guidelines and payment limit 4 2

3 2013 RHC and FQHC Payment Limits RHCs - $79.14 per visit* Urban FQHCs - $ per visit Rural FQHCs - $ per visit Updated annually based on the MEI * Except for RHCs with an exception to the payment limit 5 RHC and FQHC Medicare Resources Medicare RHC/FQHC Benefit Policy Manual, Chapter 13, pdf Medicare State Operations Manual, Appendix G, pendicestoc.pdf Medicare Claims Processing Manual, Chapter 9, pdf 6 3

4 Chapter 13 - Medicare RHC/FQHC Benefit Policy Manual Updated manual released 2/1/13 Effective 3/1/13 Completely reorganized to better access information Language revised for improved clarity 7 Chapter 13 - Medicare RHC/ FQHC Benefit Policy Manual Reflects legislative changes Health Care Safety Net Act of 2008 Medicare Improvements for Patients and Providers Act of 2008 Patient Protection and Affordable Care Act of

5 Chapter 13 - Medicare RHC/FQHC Benefit Policy Manual Includes more information based on questions frequently received by CMS central and regional staff Includes updated links to websites and resources 9 Chapter 13 - Medicare RHC/FQHC Benefit Policy Manual Section 10 General Information Overview of RHCs/FQHCs and their requirements Section 20 Location Requirements Types of designations acceptable for RHC certification, the time frame for the designation, the Census Bureau requirements, and location requirements for FQHCs 10 5

6 Chapter 13 - Medicare RHC/FQHC Benefit Policy Manual Section 30 Staffing Requirements Staffing requirements for RHCs and FQHCs, RHC waiver requirements Section 40 Visits Requirements for a billable visit, locations where visits can take place, hours of operations, when multiple visits on the same day can occur, and visits occurring during a global billing period or a 3 day payment window period 11 Chapter 13 - Medicare RHC/FQHC Benefit Policy Manual Section 50 Services What services are considered RHC/FQHC services, requirements for emergency services, application of EMTALA Section 60 Non RHC/FQHC Services Clarifies which services are not part of the RHC or FQHC benefit 12 6

7 Chapter 13 - Medicare RHC/FQHC Benefit Policy Manual Section 70 Payment Rate and Exceptions Payment rate calculations, payment limits and exceptions, cost reports, productivity standards Section 80 Patient Charges Charges, waivers, and sliding fee scale Section 90 Commingling When resources can be shared and when the sharing of resources is prohibited 13 Chapter 13 - Medicare RHC/FQHC Benefit Policy Manual Section 100 & 110 Physician Services and Incident to What physician services are billable, types of providers that can bill for physician services, billing for telehealth, hospice services, and GME What services and supplies are considered incident to physician services, who can furnish incident to services, where they can be provided, and how they are paid 14 7

8 Chapter 13 - Medicare RHC/FQHC Benefit Policy Manual Section 120 & 130 NP, PA, CNM Services and Incident to Requirements and information on payments for these services and the payment exception for PAs What services and supplies are considered incident to NP, PA, and CNM services, who can furnish incident to services, where they can be provided, and how they are paid 15 Chapter 13 - Medicare RHC/ FQHC Benefit Policy Manual Chapter 13 Section 140 & 150 CP and CSW Services and Incident to Requirements and information on payment for these services What services and supplies are considered incident to CP and CSW services, who can furnish incident to services, where they can be provided, and how they are paid 16 8

9 Chapter 13 - Medicare RHC/ FQHC Benefit Policy Manual Section 160 Outpatient Mental Health Yearly rates Section 170 PT & OT When these services can be provided and how they are billed Section Visiting Nursing Services Requirements for VNS, where these visits can take place, home health agency shortage areas 17 Chapter 13 - Medicare RHC/ FQHC Benefit Policy Manual Section 190 Telehealth Services Clarifies that RHCs and FQHCs can be originating sites but not distant site providers for telehealth services. Section 200 Hospice Services Clarifies when RHCs and FQHCs can provide services to hospice beneficiaries 18 9

10 Chapter 13 - Medicare RHC/FQHC Benefit Policy Manual Section 200 Preventive Health Services Required preventive services for RHCs and FQHCs, including vaccines, DSMT, and MNT, and information on copayment and deductibles for preventive services 19 Proposed Burden Reduction Regulation Issued - February 7, 2013 Comments period closes - April 8, 2013 Proposed rules to help health care providers operate more efficiently by getting rid of regulations that are out of date or no longer needed, without jeopardizing beneficiary safety 20 10

11 Proposed Burden Reduction Regulation - RHC Provisions Eliminates the requirement that a physician be onsite once every two weeks (RHCs and CAHs) Solicits comments on reducing barriers to services in RHCs Telehealth Hospice Home Health Other 21 CMS Regional Rural Health Coordinators Provide technical, policy, and operational assistance on rural health issues and programs 22 11

12 CMS Regional Rural Health Coordinators Region I CT, ME, MA, NH, RI, VT Rick Hoover rick.hoover@cms.hhs.gov Region II NJ, NY, PR, VI Miechal Lefkowitz miechal.lefkowitz@cms.hhs.gov Region III DE, MD, PA, VA, DC Patrick Hamilton patrick.hamilton@cms.hhs.gov 22 CMS Regional Rural Health Coordinators Region IV AL, FL, GA, KY, MS, NC, SC, TN Lana Dennis lana.dennis@cms.hhs.gov Region V- IL, IN, MI, MN, OH, WI Nicole Jacobson nicole.jacobson@cms.hhs.gov Region VI AR, LA, NM, OK, TX Kaleigh Emerson kaleigh.emerson@cms.hhs.gov 23 12

13 CMS Regional Rural Health Coordinators Region VII IA, KS, MO, NE Claudia Odgers Region VIII CO, MT, ND, SD, UT, WY Lyla Nichols Region IX AZ, CA, HI, NV, GU, CNMI, AS. MI, RoP, FSM Neal Logue Region X = AL, ID, OR, WA Teresa Cumpton teresa.cumpton@cms.hhs.gov 24 Corinne Axelrod, MPH, L.Ac., Dipl.Ac. corinne.axelrod@cms.hhs.gov