HomeMy WebLinkAboutMINUTES - 05122009 - C.25RECOMMENDATION(S):
SUPPORT Assembly Bill 1445 (Chesbro), a bill that authorizes Medi-Cal reimbursement to
federally qualified health centers and rural health clinics for a maximum of two visits for
one patient on the same day, as specified, as recommended by the Legislation Committee.
FISCAL IMPACT:
This bill has not been analyzed by a fiscal committee
BACKGROUND:
Specifically, this bill:
1) Authorizes reimbursement for a maximum of two visits, as specified, on the same day at
a single location under the following conditions:
a) After the first visit the patient suffers an illness or injury requiring additional diagnosis or
treatment; or,
b) The patient has a medical visit and another health visit.
APPROVE OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
Action of Board On: 05/12/2009 APPROVED AS RECOMMENDED OTHER
Clerks Notes:
VOTE OF SUPERVISORS
AYE:John Gioia, District I
Supervisor
Gayle B. Uilkema, District II
Supervisor
Mary N. Piepho, District III
Supervisor
Susan A. Bonilla, District IV
Supervisor
Federal D. Glover, District V
Supervisor
Contact: L. DeLaney, 5-1097
I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board
of Supervisors on the date shown.
ATTESTED: May 12, 2009
David J. Twa, County Administrator and Clerk of the Board of Supervisors
By: June McHuen, Deputy
cc:
C.25
To:Board of Supervisors
From:Legislation Committee
Date:May 12, 2009
Contra
Costa
County
Subject:SUPPORT POSITION for AB 1445 (Chesbro): Medi-Cal: Health Centers and Rural Health Clinics
2) Defines "medical visit" as a face-to-face encounter between a federally qualified health
centers (FQHC) or rural health clinics (RHC) patient and a physician, physician assistant,
nurse practitioner, certified midwife, visiting nurse, or comprehensive perinatal services
practitioner.
3) Defines "another health visit" as a face-to-face encounter between a FQHC or RHC
patient and a clinical psychologist, licensed clinical social worker, dentist, or dental
hygienist.
4) Specifies that this bill constitutes a change in the scope of services and that FQHCs and
RHCs must file a scope of service change as required by law.
5) Requires the Department of Health Care Services, no later than March 30, 2010, to seek
all necessary federal approvals in order to implement this bill.
According to the author, this bill is necessary to take advantage of the availability of federal
Medicaid funds to support mental health services for Medi-Cal patients served by federally
qualified health centers (FQHCs). The author points out that federal Medicaid law permits
reimbursement for same-day FQHC visits for mental health services. The author contends
that this bill will allow FQHCs to better integrate behavioral health services with medical
care services which is a best practice for dealing with mental health issues.
The author notes that numerous studies over the last 30 years have found high rates of
physical health problems and death among individuals with serious mental illness. In
addition, studies also reveal that less than 50% of those with mental illnesses actually seek
help for their mental health condition while 80% of those same individuals had a primary
care visit within the previous six months. The author cites these statistics to underscore the
importance of primary care providers as the first line of defense for detection and treatment
of mental illness. However, the author also points out that one in four patients referred to
specialty mental health or substance abuse services never make it to the first appointment.
The author argues that this bill will allow clinic primary care providers to make same day
referrals for mental health treatment thus increasing the chances that patients will actually
make the appointments and get the services they need.
BACKGROUND: (CONT'D)
BACKGROUND
California licenses nonprofit community clinics and many licensed community clinics are
also federally designated as FQHCs. Under federal law, FQHCs and designated RHCs are
eligible for enhanced Medicare and Medicaid (Medi-Cal in California) reimbursement.
The rationale for the enhanced reimbursement is to ensure that FQHCs do not use federal
grant funds intended for uninsured and special needs populations to back-fill for
potentially below-cost Medicare or Medi-Cal rates. FQHC services are reimbursed in
Medi-Cal on a fixed "per visit" rate rather than by individual services. FQHC provider
types are specified in existing statue as those for which a visit can be billed in a single
day: physician, physician assistant, nurse practitioner, certified nurse midwife, clinical
psychologist, licensed clinical social worker, or a visiting nurse.
Current law only allows multiple billable visits in a single day if they are for medical and
dental services. Only mental health visits provided by a clinical psychologist are
separately billable FQHC visits, but not for services on the same day as a medical visit.
Mental health visits are currently coded for Medi-Cal billing purposes as a medical visit
for which only one visit per patient per day is allowed. The federal Substance Abuse and
Mental Health Services Administration released a report in July 2008, titled
"Reimbursement of Mental Health Services in Primary Care Settings," which identified
potential barriers and solutions for reimbursement of mental health services. This report
was developed to improve access to mental health services for persons with public
insurance and recommended authorizing same-day services billing for separate
practitioners as proposed in this bill.
FQHCs are federally funded public or nonprofit community clinics that serve a high
number of both Medi-Cal and uninsured patients. FQHCs are open door providers that
treat patients on a sliding fee scale basis and make available a comprehensive array of
health and social services regardless of the patient's ability to pay. FQHCs are CHCs, a
federal grant program established in the 1960s to improve access to primary and
preventive care for individuals in medically underserved communities and special
populations, such as the medically uninsured, homeless persons, and migrant
farmworkers. In 1996, the health center programs (migrant health centers, community
health centers, health care for the homeless, and health centers for residents of public
housing) were consolidated under Section 330 of the federal PHS Act. All PHS grant
recipients are nonprofit, public, or otherwise tax-exempt entities. CHCs receiving PHS
grant funds, and meeting specific federal requirements, are FQHCs entitled to higher
reimbursement under Medicare and Medicaid.
PRIOR LEGISLATION
a) SB 260 (Steinberg) of 2007, a substantially similar bill, was also vetoed. In returning
SB 260, the Governor stated, "While I support improving access to health care services,
including mental health services, I cannot support this bill as it would increase General
Fund pressure at a time of continuing budget challenges?separate billing for mental
health services would lead to increased costs that our state cannot afford."
b) SB 36 (Chesbro), Chapter 527, Statutes of 2003, creates a statutory structure for the
implementation of a PPS for Medi-Cal reimbursement of FQHCs, in response to the
federal Medicare, Medicaid, and State Children's Health Insurance Program Benefits
Improvement and Protection Act of 2000 (BIPA) which phased out cost-based
reimbursement for FQHC/RHCs and required states to implement a PPS or
federally-approved alternative.
c) SB 1413 (Chesbro) of 2002 would have restructured Medi-Cal reimbursement for
FQHCs in response to BIPA and also contained a provision similar to the changes
proposed in this bill. Governor Gray Davis vetoed SB 1413.
SUPPORT
The sponsor of this bill, the California Primary Care Association, writes in support that
this bill will allow FQHC clinics to more effectively develop and implement integrated
primary and behavioral health services, which, in the purest form, places the mental
health professional into the primary care setting as a team member working closely with
primary care providers. In these clinics, the primary care provider may make a "warm
handoff" to the on-site mental health professional when they note the need for a further
mental health assessment, allowing the mental health practitioner to promptly assess and
treat the patient.
The California Mental Health Directors' Association (CMHDA) supports this bill and
believes that allowing billing for same day medical and mental health visits will
maximize federal Medicaid funds and improve continuity of care for clinic patients.
CMHDA points out that same day services are the hallmark of a fully integrated primary
behavioral health care model. The California Medical Association writes that medical
and mental health services are important components of an integrated strategy for
maintaining and improving health for Medi-Cal beneficiaries and points out that mental
health treatment can improve patient compliance with chronic disease management and
treatment.
REGISTERED SUPPORT / OPPOSITION:
Support
California Primary Care Association (Sponsor) Alliance for Rural Health AltaMed
Health Services American College of Obstetricians and Gynecologists California
Association of Marriage and Family Therapists California Association of Rural Health
Clinics California Chiropractic Association California Hospital Association California
Psychiatric Association California Psychological Association California School Centers
Psychiatric Association California Psychological Association California School Centers
Association California School Health Centers Association California Society for Clinical
Social Work California State Association of Counties California State Rural Health
Association Community Clinic Association County of San Bernardino County of Santa
Clara Disability Rights California Eisner Pediatric & Family Medical Center North Coast
Clinics Network Six Rivers Planned Parenthood Urban Counties Caucus 46 community
clinics
Opposition
None on file.
ATTACHMENTS
Bill Text AB 1445
AMENDED IN ASSEMBLY APRIL 15, 2009
california legislature—2009–10 regular session
ASSEMBLY BILL No. 1445
Introduced by Assembly Member Chesbro
February 27, 2009
An act to amend Section 14132.100 of the Welfare and Institutions
Code, relating to Medi-Cal.
legislative counsel’s digest
AB 1445, as amended, Chesbro.Medi-Cal. Medi-Cal: federally
qualified health centers and rural health clinics.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services pursuant
to which medical benefits are provided to public assistance recipients
and certain other low-income persons. Existing law provides that
federally qualified health center (FQHC) services and rural health clinic
(RHC) services, as defined, are covered benefits under the Medi-Cal
program, to be reimbursed, to the extent that federal financial
participation is obtained, to providers on a per-visit basis. “Visit” is
defined as a face-to-face encounter between a patient of a federally
qualified health center or a rural health clinic and specified health care
professionals. Existing law allows an FQHC or RHC to apply for an
adjustment to its per-visit rate based on a change in the scope of services
it provides.
This bill would provide that more than one encounter between a
patient and the same health care professional on the same day and at a
single location may each be separately reimbursed in specified
circumstances. The bill would also provide that, under specified
circumstances, visits with different health care professionals on the
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same day of service may be billed as separate visits. The bill would
require the department, by March 30, 2010, to seek all necessary federal
approvals in order to implement the bill, including any necessary
amendments to the state Medi-Cal plan.
This bill would provide that a maximum of 2 visits, as defined, taking
place on the same day at a single location shall be reimbursed when
either after the first visit the patient suffers illness or injury requiring
additional diagnosis or treatment or the patient has a medical visit, as
defined, and another health visit, as defined, or both. The bill would
provide that these provisions shall constitute a change in the scope of
services and would require an FQHC or RHC to file a scope of service
change to the extent required by applicable law.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
The people of the State of California do enact as follows:
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SECTION 1.Section 14132.100 of the Welfare and Institutions
Code is amended to read:
14132.100.(a) The federally qualified health center services
described in Section 1396d(a)(2)(C) of Title 42 of the United States
Code are covered benefits.
(b) The rural health clinic services described in Section
1396d(a)(2)(B) of Title 42 of the United States Code are covered
benefits.
(c) Federally qualified health center services and rural health
clinic services shall be reimbursed on a per-visit basis in
accordance with the definition of “visit” set forth in subdivision
(g).
(d) Effective October 1, 2004, and on each October 1, thereafter,
until no longer required by federal law, federally qualified health
center (FQHC) and rural health clinic (RHC) per-visit rates shall
be increased by the Medicare Economic Index applicable to
primary care services in the manner provided for in Section
1396a(bb)(3)(A) of Title 42 of the United States Code. Prior to
January 1, 2004, FQHC and RHC per-visit rates shall be adjusted
by the Medicare Economic Index in accordance with the
methodology set forth in the state plan in effect on October 1,
2001.
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(e) (1) An FQHC or RHC may apply for an adjustment to its
per-visit rate based on a change in the scope of services provided
by the FQHC or RHC. Rate changes based on a change in the
scope of services provided by an FQHC or RHC shall be evaluated
in accordance with Medicare reasonable cost principles, as set
forth in Part 413 (commencing with Section 413.1) of Title 42 of
the Code of Federal Regulations, or its successor.
(2) Subject to the conditions set forth in subparagraphs (A) to
(D), inclusive, of paragraph (3), a change in scope of service means
any of the following:
(A) The addition of a new FQHC or RHC service that is not
incorporated in the baseline prospective payment system (PPS)
rate, or a deletion of an FQHC or RHC service that is incorporated
in the baseline PPS rate.
(B) A change in service due to amended regulatory requirements
or rules.
(C) A change in service resulting from relocating or remodeling
an FQHC or RHC.
(D) A change in types of services due to a change in applicable
technology and medical practice utilized by the center or clinic.
(E) An increase in service intensity attributable to changes in
the types of patients served, including, but not limited to,
populations with HIV or AIDS, or other chronic diseases, or
homeless, elderly, migrant, or other special populations.
(F) Any changes in any of the services described in subdivision
(a) or (b), or in the provider mix of an FQHC or RHC or one of
its sites.
(G) Changes in operating costs attributable to capital
expenditures associated with a modification of the scope of any
of the services described in subdivision (a) or (b), including new
or expanded service facilities, regulatory compliance, or changes
in technology or medical practices at the center or clinic.
(H) Indirect medical education adjustments and a direct graduate
medical education payment that reflects the costs of providing
teaching services to interns and residents.
(I) Any changes in the scope of a project approved by the federal
Centers for Medicare and Medicaid Services (CMS) Health
Resources and Service Administration (HRSA).
(3) No change in costs shall, in and of itself, be considered a
scope-of-service change unless all of the following apply:
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(A) The increase or decrease in cost is attributable to an increase
or decrease in the scope of services defined in subdivisions (a) and
(b), as applicable.
(B) The cost is allowable under Medicare reasonable cost
principles set forth in Part 413 (commencing with Section 413) of
Subchapter B of Chapter 4 of Title 42 of the Code of Federal
Regulations, or its successor.
(C) The change in the scope of services is a change in the type,
intensity, duration, or amount of services, or any combination
thereof.
(D) The net change in the FQHC’s or RHC’s rate equals or
exceeds 1.75 percent for the affected FQHC or RHC site. For
FQHCs and RHCs that filed consolidated cost reports for multiple
sites to establish the initial prospective payment reimbursement
rate, the 1.75-percent threshold shall be applied to the average
per-visit rate of all sites for the purposes of calculating the cost
associated with a scope-of-service change. “Net change” means
the per-visit rate change attributable to the cumulative effect of all
increases and decreases for a particular fiscal year.
(4) An FQHC or RHC may submit requests for scope-of-service
changes once per fiscal year, only within 90 days following the
beginning of the FQHC’s or RHC’s fiscal year. Any approved
increase or decrease in the provider’s rate shall be retroactive to
the beginning of the FQHC’s or RHC’s fiscal year in which the
request is submitted.
(5) An FQHC or RHC shall submit a scope-of-service rate
change request within 90 days of the beginning of any FQHC or
RHC fiscal year occurring after the effective date of this section,
if, during the FQHC’s or RHC’s prior fiscal year, the FQHC or
RHC experienced a decrease in the scope of services provided that
the FQHC or RHC either knew or should have known would have
resulted in a significantly lower per-visit rate. If an FQHC or RHC
discontinues providing onsite pharmacy or dental services, it shall
submit a scope-of-service rate change request within 90 days of
the beginning of the following fiscal year. The rate change shall
be effective as provided for in paragraph (4). As used in this
paragraph, “significantly lower” means an average per-visit rate
decrease in excess of 2.5 percent.
(6) Notwithstanding paragraph (4), if the approved
scope-of-service change or changes were initially implemented
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on or after the first day of an FQHC’s or RHC’s fiscal year ending
in calendar year 2001, but before the adoption and issuance of
written instructions for applying for a scope-of-service change,
the adjusted reimbursement rate for that scope-of-service change
shall be made retroactive to the date the scope-of-service change
was initially implemented. Scope-of-service changes under this
paragraph shall be required to be submitted within the later of 150
days after the adoption and issuance of the written instructions by
the department, or 150 days after the end of the FQHC’s or RHC’s
fiscal year ending in 2003.
(7) All references in this subdivision to “fiscal year” shall be
construed to be references to the fiscal year of the individual FQHC
or RHC, as the case may be.
(f) (1) An FQHC or RHC may request a supplemental payment
if extraordinary circumstances beyond the control of the FQHC
or RHC occur after December 31, 2001, and PPS payments are
insufficient due to these extraordinary circumstances. Supplemental
payments arising from extraordinary circumstances under this
subdivision shall be solely and exclusively within the discretion
of the department and shall not be subject to subdivision (m). These
supplemental payments shall be determined separately from the
scope-of-service adjustments described in subdivision (e).
Extraordinary circumstances include, but are not limited to, acts
of nature, changes in applicable requirements in the Health and
Safety Code, changes in applicable licensure requirements, and
changes in applicable rules or regulations. Mere inflation of costs
alone, absent extraordinary circumstances, shall not be grounds
for supplemental payment. If an FQHC’s or RHC’s PPS rate is
sufficient to cover its overall costs, including those associated with
the extraordinary circumstances, then a supplemental payment is
not warranted.
(2) The department shall accept requests for supplemental
payment at any time throughout the prospective payment rate year.
(3) Requests for supplemental payments shall be submitted in
writing to the department and shall set forth the reasons for the
request. Each request shall be accompanied by sufficient
documentation to enable the department to act upon the request.
Documentation shall include the data necessary to demonstrate
that the circumstances for which supplemental payment is requested
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meet the requirements set forth in this section. Documentation
shall include all of the following:
(A) A presentation of data to demonstrate reasons for the
FQHC’s or RHC’s request for a supplemental payment.
(B) Documentation showing the cost implications. The cost
impact shall be material and significant, two hundred thousand
dollars ($200,000) or 1 percent of a facility’s total costs, whichever
is less.
(4) A request shall be submitted for each affected year.
(5) Amounts granted for supplemental payment requests shall
be paid as lump-sum amounts for those years and not as revised
PPS rates, and shall be repaid by the FQHC or RHC to the extent
that it is not expended for the specified purposes.
(6) The department shall notify the provider of the department’s
discretionary decision in writing.
(g) (1) An FQHC or RHC “visit” means a face-to-face
encounter between an FQHC or RHC patient and a physician,
physician assistant, nurse practitioner, certified nurse midwife,
clinical psychologist, licensed clinical social worker, or a visiting
nurse. For purposes of this section, “physician” shall be interpreted
in a manner consistent with the Centers for Medicare and Medicaid
Services’ Medicare Rural Health Clinic and Federally Qualified
Health Center Manual (Publication 27), or its successor, only to
the extent that it defines the professionals whose services are
reimbursable on a per-visit basis and not as to the types of services
that these professionals may render during these visits and shall
include a medical doctor, osteopath, podiatrist, dentist, optometrist,
and chiropractor. A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a comprehensive perinatal
services practitioner, as defined in Section 51179.1 51179.7 of
Title 22 of the California Code of Regulations, providing
comprehensive perinatal services, a four-hour day of attendance
at an adult day health care center, and any other provider identified
in the state plan’s definition of an FQHC or RHC visit.
(2) (A) A visit shall also include a face-to-face encounter
between an FQHC or RHC patient and a dental hygienist or a
dental hygienist in alternative practice.
(B) Notwithstanding subdivision (e), an FQHC or RHC that
currently includes the cost of the services of a dental hygienist in
alternative practice for the purposes of establishing its FQHC or
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RHC rate shall apply for an adjustment to its per-visit rate, and,
after the rate adjustment has been approved by the department,
shall bill these services as a separate visit. However, multiple
encounters with dental professionals that take place on the same
day shall constitute a single visit. The department shall develop
the appropriate forms to determine which FQHC’s or RHC rates
shall be adjusted and to facilitate the calculation of the adjusted
rates. An FQHC’s or RHC’s application for, or the department’s
approval of, a rate adjustment pursuant to this subparagraph shall
not constitute a change in scope of service within the meaning of
subdivision (e). An FQHC or RHC that applies for an adjustment
to its rate pursuant to this subparagraph may continue to bill for
all other FQHC or RHC visits at its existing per-visit rate, subject
to reconciliation, until the rate adjustment for visits between an
FQHC or RHC patient and a dental hygienist or a dental hygienist
in alternative practice has been approved. Any approved increase
or decrease in the provider’s rate shall be made within six months
after the date of receipt of the department’s rate adjustment forms
pursuant to this subparagraph and shall be retroactive to the
beginning of the fiscal year in which the FQHC or RHC submits
the request, but in no case shall the effective date be earlier than
January 1, 2008.
(C) An FQHC or RHC that does not provide dental hygienist
or dental hygienist in alternative practice services, and later elects
to add these services, shall process the addition of these services
as a change in scope of service pursuant to subdivision (e).
(h) If FQHC or RHC services are partially reimbursed by a
third-party payer, such as a managed care entity (as defined in
Section 1396u-2(a)(1)(B) of Title 42 of the United States Code),
the Medicare Program, or the Child Health and Disability
Prevention (CHDP) program, the department shall reimburse an
FQHC or RHC for the difference between its per-visit PPS rate
and receipts from other plans or programs on a contract-by-contract
basis and not in the aggregate, and may not include managed care
financial incentive payments that are required by federal law to
be excluded from the calculation.
(i) (1) An entity that first qualifies as an FQHC or RHC in the
year 2001 or later, a newly licensed facility at a new location added
to an existing FQHC or RHC, and any entity that is an existing
FQHC or RHC that is relocated to a new site shall each have its
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reimbursement rate established in accordance with one of the
following methods, as selected by the FQHC or RHC:
(A) The rate may be calculated on a per-visit basis in an amount
that is equal to the average of the per-visit rates of three comparable
FQHCs or RHCs located in the same or adjacent area with a similar
caseload.
(B) In the absence of three comparable FQHCs or RHCs with
a similar caseload, the rate may be calculated on a per-visit basis
in an amount that is equal to the average of the per-visit rates of
three comparable FQHCs or RHCs located in the same or an
adjacent service area, or in a reasonably similar geographic area
with respect to relevant social, health care, and economic
characteristics.
(C) At a new entity’s one-time election, the department shall
establish a reimbursement rate, calculated on a per-visit basis, that
is equal to 100 percent of the projected allowable costs to the
FQHC or RHC of furnishing FQHC or RHC services during the
first 12 months of operation as an FQHC or RHC. After the first
12-month period, the projected per-visit rate shall be increased by
the Medicare Economic Index then in effect. The projected
allowable costs for the first 12 months shall be cost settled and the
prospective payment reimbursement rate shall be adjusted based
on actual and allowable cost per visit.
(D) The department may adopt any further and additional
methods of setting reimbursement rates for newly qualified FQHCs
or RHCs as are consistent with Section 1396a(bb)(4) of Title 42
of the United States Code.
(2) In order for an FQHC or RHC to establish the comparability
of its caseload for purposes of subparagraph (A) or (B) of paragraph
(1), the department shall require that the FQHC or RHC submit
its most recent annual utilization report as submitted to the Office
of Statewide Health Planning and Development, unless the FQHC
or RHC was not required to file an annual utilization report. FQHCs
or RHCs that have experienced changes in their services or
caseload subsequent to the filing of the annual utilization report
may submit to the department a completed report in the format
applicable to the prior calendar year. FQHCs or RHCs that have
not previously submitted an annual utilization report shall submit
to the department a completed report in the format applicable to
the prior calendar year. The FQHC or RHC shall not be required
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to submit the annual utilization report for the comparable FQHCs
or RHCs to the department, but shall be required to identify the
comparable FQHCs or RHCs.
(3) The rate for any newly qualified entity set forth under this
subdivision shall be effective retroactively to the later of the date
that the entity was first qualified by the applicable federal agency
as an FQHC or RHC, the date a new facility at a new location was
added to an existing FQHC or RHC, or the date on which an
existing FQHC or RHC was relocated to a new site. The FQHC
or RHC shall be permitted to continue billing for Medi-Cal covered
benefits on a fee-for-service basis under its existing provider
number until it is informed of its new FQHC or RHC provider
number, and the department shall reconcile the difference between
the fee-for-service payments and the FQHC’s or RHC’s prospective
payment rate at that time.
(j) Visits occurring at an intermittent clinic site, as defined in
subdivision (h) of Section 1206 of the Health and Safety Code, of
an existing FQHC or RHC, or in a mobile unit as defined by
paragraph (2) of subdivision (b) of Section 1765.105 of the Health
and Safety Code, shall be billed by and reimbursed at the same
rate as the FQHC or RHC establishing the intermittent clinic site
or the mobile unit, subject to the right of the FQHC or RHC to
request a scope-of-service adjustment to the rate.
(k) More than one encounter with the same health care
professional, of the type described in subdivision (g), that takes
place on the same day and at a single location may be separately
reimbursed as a visit if after the first encounter, the health center
or clinic patient suffers illness or injury requiring additional
diagnosis or treatment. Multiple visits on the same day of services
may be billed and separately reimbursed if the health center or
clinic patient receives services from more than one health care
professional, of the type described in subdivision (g), and the nature
of the services or the patient diagnoses are unrelated. A medical
visit and a mental health services visit with a licensed professional
that takes place on the same day may be billed as two separate
visits. A medical visit and a visit with a dental professional, as
authorized by subdivision (g), on the same day may be billed as
two separate visits.
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(k) (1) A maximum of two visits, as defined in subdivision (g),
taking place on the same day at a single location shall be
reimbursed when one or more of the following conditions exist:
(A) After the first visit the patient suffers illness or injury
requiring additional diagnosis or treatment.
(B) (i) The patient has a medical visit and another health visit.
(ii) (I) For purposes of this subdivision, “medical visit” means
a face-to-face encounter between an FQHC or RHC patient and
a physician, physician assistant, nurse practitioner, certified nurse
midwife, visiting nurse, or a comprehensive perinatal services
practitioner, as defined in Section 51179.7 of Title 22 of the
California Code of Regulations, providing comprehensive perinatal
services.
(II) For purposes of this subdivision, “another health visit”
means a face-to-face encounter between an FQHC or RHC patient
and a clinical psychologist, licensed clinical social worker, dentist,
dental hygienist, or registered dental hygienist in alternative
practice.
(2) This subdivision shall constitute a change in the scope of
services for purposes of paragraph (2) of subdivision (e). In order
to comply with this subdivision, an FQHC or RHC shall file a
scope of service change to the extent required by applicable law.
(l) An FQHC or RHC may elect to have pharmacy or dental
services reimbursed on a fee-for-service basis, utilizing the current
fee schedules established for those services. These costs shall be
adjusted out of the FQHC’s or RHC’s clinic base rate as
scope-of-service changes. An FQHC or RHC that reverses its
election under this subdivision shall revert to its prior rate, subject
to an increase to account for all MEI increases occurring during
the intervening time period, and subject to any increase or decrease
associated with applicable scope-of-services adjustments as
provided in subdivision (e).
(m) FQHCs and RHCs may appeal a grievance or complaint
concerning ratesetting, scope-of-service changes, and settlement
of cost report audits, in the manner prescribed by Section 14171.
The rights and remedies provided under this subdivision are
cumulative to the rights and remedies available under all other
provisions of law of this state.
(n) (1) Except as provided in paragraph (2), the department
shall, by no later than March 30, 2008, promptly seek all necessary
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federal approvals in order to implement this section, including any
amendments to the state plan.
(2) The department, no later than March 30, 2010, shall promptly
seek all necessary federal approvals in order to implement
subdivision (k), including any necessary amendments to the state
plan.
(3) To the extent that any element or requirement of this section
is not approved, the department shall submit a request to the federal
Centers for Medicare and Medicaid Services for any waivers that
would be necessary to implement this section.
(o) The department shall implement this section only to the
extent that federal financial participation is obtained.
O
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