Rural Health Clinics Captain Corinne Axelrod, MPH, L.Ac., Dipl.Ac. Centers for Medicare and Medicaid Services Center for Medicare, Hospital and Ambulatory Policy Group NOSORH March 26, 2012 Rural Health Clinic Services Act of 1977 Enacted to address an inadequate supply of physicians serving Medicare beneficiaries in underserved rural areas, and to increase the utilization of NPs and PAs in rural areas Established Section 1861(aa) of the Social Security Act which authorized payment to RHCs on a cost basis, subject to reasonableness and payment limits 2 1
Rural Health Clinic Services Act of 1977 Required that RHCs be located in: Non urbanized areas (Census Bureau), and Areas currently designated or certified by HRSA as a shortage area Allowed existing RHCs to remain in the program even if they no longer met the location requirements ( grandfather clause) 3 Balanced Budget Act 1997 Amended 1861(aa): Removed the grandfather clause so that existing RHCs would also have to be in nonurbanized and currently designated areas Required an exceptions process for existing RHCs that are essential to the delivery of primary care in the service area 4 2
Regulations to Implement the BBA February 2000 Proposed Rule (P1) December 2003 Final Rule (F1) September 2006 Suspension of Final Rule due to MMA requirement that no more than 3 years could elapse between a proposed and final rule June 2008 New Proposed Rule (P2) 5 RHCs Defined ( 1861(aa)(2) of the Social Security Act) Facilities that are engaged primarily in providing outpatient services that are typically furnished in a physician s office Independent stand alone or freestanding or Provider based an integral and subordinate part of a hospital (including CAHs), SNF, or HHA 6 3
RHC Services Physician services Services and supplies incident to the services of a physician NP, PA, CNM, CP, and CSW services Services and supplies incident to the services of a NP, PA, CNM, CP, and CSW Part B drugs that are furnished by or incident to services of a RHC provider 7 RHC Services (con t) Visiting nurse services to the homebound in an area where CMS has certified that there is a shortage of Home Health Agencies Certain preventive services (Influenza, Pneumococcal, Hep B vaccinations, IPPE, AWV, and Medicare covered px services recommended by the USPSTF with a grade of A or B 8 4
Medicare Certification as a RHC To qualify as a RHC, a clinic must be located in: A non urbanized area, as defined by the U.S. Census Bureau; and An area currently designated by HRSA as a Primary Care Geographic or Population Based HPSA Medically Underserved Area (not MUP) Governor designated and Secretary certified shortage area 9 RHC Reimbursement RHCS are paid an all inclusive rate per visit for qualified primary and preventive health services Rate is determined for each RHC by dividing allowable costs by the number of actual visits, subject to screening guidelines for evaluating the reasonableness of the RHC s productivity, and payment limit (except for RHCs with an exception to the payment limit) 10 5
RHC Visits RHC visits are medically necessary, face toface (one on one) encounters between the beneficiary and a physician, NP, PA, CNM, CP, or CSW during which one or more RHC services are furnished In certain limited situations, RHC visits may also include a visit by a RN or a LPN to a homebound beneficiary 11 Location of RHC Services May be provided at any location (RHC facility, patient s residence, ALF, Medicare covered Part A SNF, scene of an accident) except: An inpatient or outpatient hospital (including CAHs) A facility that has specific requirements that preclude RHC visits (e.g. CORF, FQHC, hospice, etc.) 12 6
Key RHC Requirements Employ a NP or PA Have a NP, PA, or CNM working at the clinic (not off site) at least 50 percent of the time the RHC operates Directly furnish routine diagnostic and laboratory services 13 Key RHC Requirements (con t) Have arrangements with one or more hospitals to furnish medically necessary services that are not available at the RHC Have available drugs and biologicals necessary for the treatment of emergencies Furnish onsite six laboratory tests (urine, hemoglobin or hematocrit, blood sugar, stool specimens, pregnancy tests; and primary culturing for transmittal to a certified laboratory) 14 7
Key RHC Requirements (con t) Have an annual program evaluation Not be a rehabilitation agency or a facility that is primarily for the treatment of mental disease Not be a Federally Qualified Health Center; and Meet other applicable State and Federal requirements 15 Employ a NP or PA May be full or part time Can be fulfilled through any combination of NPs and PAs Cannot be someone who is: Employed by a hospital that has an ownership interest in the RHC but is not physically present in the RHC A CNM A locum tenens 16 8
Single/Multiple Visits Encounters at a single location on the same day with more than one RHC provider, or multiple encounters with the same health provider, constitute a single visit, regardless of the length or complexity of the visit 17 Exceptions When the patient: Suffers an illness or injury requiring additional diagnosis or treatment on the same day subsequent to the first encounter; or Has a medical visit and a psychological visit with a CP or CSW on the same day; or Has a IPPE and a separate medical and/or psychological visit on the same day 18 9
Annual Wellness Visit (AWV) Can be billed as a visit if it is the only medical service provided on that day If furnished on the same day as a medical visit, it is not a separately billable visit If provided on the same day as psychological visit with an RHC, then two visits can be billed 19 RHC Payments RHCs receive cost based reimbursement for a defined set of core physician and certain nonphysician outpatient services. Payment is based on an all inclusive payment methodology, subject to a maximum payment per visit and annual reconciliation. 20 10
RHC Payments (con t) The per visit limit does not apply to RHCs that are an integral and subordinate part of a hospital with fewer than 50 beds. Laboratory tests are paid separately. 21 Co payment & Deductibles Copayment is 20% of charges except for: Outpatient mental health treatment services 2012 copayment 40% 2013 copayment 35% 2014 copayment 20% Certain preventive services no coinsurance or deductible 22 11
Rural Health Clinics Approximately 3,800 RHCs providing access to primary care services in underserved rural areas http://www.cms.gov/center/rural.asp List of RHCs, manuals, forms, policy memos, etc. 23 Resources Medicare Benefit Policy Manual, Chapter 13, https://www.cms.gov/manuals/downloads/bp10 2c13.pdf Medicare State Operations Manual, Appendix G, http://www.cms.gov/manuals/downloads/som10 7_Appendicestoc.pdf Medicare Claims Processing Manual, Chapter 9, http://www.cms.gov/manuals/downloads/clm10 4c09.pdf 24 12
Regional Rural Health Coordinators Provide technical, policy, and operational assistance on rural health issues 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 25 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 Christine Davidson christine.davidson@cms.hhs.gov Region VI AR, LA, NM, OK, TX Becky Peal Sconce becky.pealsconce@cms.hhs.gov 26 13
Regional Rural Health Coordinators Region VII IA, KS, MO, NE Claudia Odgers claudia.odgers@cms.hhs.gov Region VIII CO, MT, ND, SD, UT, WY Lyla Nichols lyla.nichols@cms.hhs.gov Region IX AZ, CA, HI, NV, GU, CNMI, AS. MI, RoP, FSM Neal Logue neal.logue@cms.hhs.gov Region X = AL, ID, OR, WA Teresa Cumpton teresa.cumpton@cms.hhs.gov 27 HPSA Bonus Payments Captain Corinne Axelrod, MPH, L.Ac., Dipl.Ac. Centers for Medicare and Medicaid Services Center for Medicare, Hospital and Ambulatory Policy Group NOSORH March 26, 2012 14
Health Professional Shortage Area (HPSA) Bonus Program Purpose of HPSA Designations: To identify areas of greater need for health care services in order to direct limited healthcare professional resources to people in those areas. Purpose of Medicare HPSA Bonus To provide an incentive for physicians serving the Medicare population to practice in shortage areas 29 HPSA Bonus Requirements Services must be furnished in an area that is a: Geographic Primary Care HPSA (all physicians) Geographic Mental Health HPSA (psychiatrists only) 30 15
HPSA Bonus Eligibility Area must be designated as of December 31 of the prior year Determined Annually 31 HPSA Bonus Payment 10% based on the amount paid for professional services furnished by the physician Paid either automatically or if the AQ modifier is on the claim 32 16
Automatic Payment of the HPSA Bonus Zip code of where the service is furnished must fall entirely within the designated area Must be designated by the date the list of zip codes for automatic payment was created 33 AQ Modifier for the HPSA Bonus Only use if the area was in a geographic primary care (or mental health) HPSA as of December 31 of the prior year Post payment review and recoupment if used incorrectly 34 17
HPSA Bonus Education and Outreach Physicians who don t know that they are eligible for the Medicare HPSA physician bonus and must use the modifier to receive payment Physicians who don t know that their eligibility for the bonus is determined annually and they may no longer be eligible to use the AQ modifier on their claims 35 Questions?????????? 36 18
Corinne Axelrod, MPH, L.Ac., Dipl.Ac. corinne.axelrod@cms.hhs.gov 410 786 5620 37 19