Wisconsin Office of Rural Health Hospital Finance Workshop Anne Dopp anne.dopp@dhs.wisconsin.gov...

Wisconsin Office of Rural HealthHospital Finance Workshop

Anne Doppanne.dopp@dhs.wisconsin.gov

Todd Novatnova@hallrender.com

HPSAs and RHCs: An Overview of Current Benefits, Current

Requirements, and New Developments

August 19, 2009

Agenda

1. Current RHC conditions of participation2. Current RHC benefits3. CMS Proposed Rule for RHCs (including

shortage designation requirement)4. HPSA 101 for RHCs:

HPSA types & requirements for RHCs HPSA linked benefits Governor’s Shortage Designation status

3

Current RHC CoPs Location – Rural and Underserved

Rural: Non-MSA or rural census tract Shortage: HPSA, MUA or Governor's Shortage

HPSA Update Requirement New RHCs: Updated in preceding 3 years Existing RHCs: Grandfathered

4

Current RHC CoPs

Physical Plant Preventive maintenance program (general equip., patient care equip., drug/biological stored appropriately, housekeeping)

Emergency Procs. (staff training, exit signs, etc.)

5

Current RHC CoPs

Organizational Structure Medical Director Policies and lines of authority in writing

6

Current RHC CoPs

Staffing One or more physicians – at least once every 2 weeks

Medical direction Available for emergencies

One or more midlevels (NP, PA, CNM, CSW, Clinical Psychologist)

At least 50% of RHC working hours

7

Current RHC CoPs

Staffing (cont.) Physician and midlevel joint duties

Develop, execute and periodically review written policies and services

8

Current RHC CoPs RHC Services

Outpatient primary services – conditions which cause a patient to present at a physician's office

Services commonly furnished in physician office or at system entry point

Consistent with written policies Developed by "group of professional personnel" that includes 1+ physicians and 1+ midlevels. At least 1 member NOT member of RHC staff

Reviewed at least annually Patient care, records, drug storage, etc.

9

Current RHC CoPs RHC Direct Services

Furnished by clinic or center staff Lab: Urinalysis, hemoglobin, glucose, occult blood, pregnancy, primary culturing,

Emergency: Common first response procedures and drugs (antibiotics, anticonvulsants, local anesthetics, etc.)

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Current RHC CoPs Arrangements

Must have arrangement or agreement with Medicare or Medicaid provider to furnish

Inpatient care Physician services Specialized diagnostics (imaging and lab)

Records Must maintain records system consistent with policies managed by designated staff person, among other requirements.

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Current RHC CoPs Program Evaluation

Must conduct comprehensive annual program evaluation

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Payment for RHC Services

All-inclusive rate for each visit

Subject to per-visit limit Based on FI/MAC calculated cost per visit

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Payment for RHC Services

Deductible/Coinsurance After deductible is satisfied, RHCs paid 80% of all-inclusive rate

Patient responsible for coinsurance amount of 20% percent of charges (not per-visit rate)

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Payment for RHC Services

Exceptions to per visit limit Provider based to hospitals

With < 50 beds Average daily census < 41 AND both:

SCH UIC level 8 or 9

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RHC Proposed Changes -CoPs and Payment Provisions

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RHC Proposed CoP Changes

Status February 28, 2000 – Proposed Rule December 24, 2003 – Final Rule September 22, 2006 – Suspended effectiveness of Final Rule

> 3 years before 2003 Rule was finalized June 28, 2008 Proposed Rule – "Re-implementing" December 2003 Final Rule

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RHC Proposed Changes In CoP (cont.)

RHC Location Requirements: Rural and Shortage

But what if the HPSA isn't updated?

Current

Existing RHCs – grandfatheredNew RHCs – tough noogies (or is it

nuggies?)

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RHC Proposed Changes In CoP (cont.)

What if the HPSA isn't updated?

Proposed

Grandfather rule terminated – decertification possible

Termination automatically effective 180 days after failure to comply with location requirements

Would be able to avoid immediate decertification by

Submitting application to update shortage area; or Submitting essential provider application

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RHC Proposed Changes In CoP (cont.) Impact of Provider-Based RHC Decertification on CAH Status Grandfathered provider-based clinic (1/1/08) – can be within 35 miles of another hospital

CAHs can convert existing clinic (provider-based or not) to a provider-based RHC, CAH status not compromised

Will decertification of that RHC jeopardize CAH?

20

RHC Proposed Changes In CoP (cont.)

ProposedIf in UA or non-shortage area, can apply for one of four:

"Essential Provider Exceptions" But First:

In Level 4 RUCA; AND At least 51% of patients reside in non-urban area (or are adjacent thereto)

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RHC Proposed Changes In CoP (cont.)

1. Sole Community Provider Either 25 miles from nearest "participating primary care provider;" or At least 15 miles and 30 minutes from nearest "participating primary care

provider"2. Major Community Provider

Medicare/Medicaid low income and uninsured patient utilization rate >= 51%; or low income patient utilization rate >= to 31%; and

Is accepting major share of Medicare/Medicaid low income and uninsured patients, regardless of ability to pay relative to other providers in the area

3. Specialty Clinic OB/GYN or Peds

4. Extremely Rural Provider Accepting Medicare/Medicaid low income and uninsured patients regardless of

ability to pay and located in a "frontier county" (<6 ppsm) or a RUCA Level 10

RHC must submit an exception request – not State PCO, not automatic

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RHC Proposed Changes In CoP (cont.)

Staffing IssuesCurrent

RHCs required to employ all midlevels providing services

Proposed Non-physician practitioners may furnish services under contract

At least one must be directly employed at all times

Signed contract with responsibilities/standards

1 year midlevel staffing waiver available

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RHC Proposed Changes In CoP (cont.)

Other Proposed Changes

QAPI program Infection control program Post hours of operation Required common emergency equipment

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RHC Proposed Changes In CoP (cont.)

Payment IssuesCurrent

RHCs/FQHCs receive 80% of reasonable costs regardless of deductible and coinsurance amounts billed to Medicare beneficiaries

Proposed

Payment equal to reasonable costs less coinsurance and deductible amounts billed

In no case may total payment (including copays) exceed 80% of reasonable costs

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Current

Per visit payment limit exception currently available to hospital-based RHCs (fewer than 50 beds)

Proposed

New hospital-based exception to per visit limit if: SCH or EACH located in a Level 9 or Level 10 RUCA and

Average daily patient census that does not exceed 40

RHC Proposed Changes In CoP (cont.)

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HPSA 101 for RHCs

Highlights from the complex world of federal shortage designation!

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Types of Federal Shortage Designations

Health Professional Shortage Area (HPSA) – shortage of providers for population

115 primary care, 73 dental & 105 mental health

Medically Underserved Area/Population (MUA/MUP) – provider shortage plus other population need (infant, aging, low-income)

74 MUA/MUPs

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HPSA – General Criteria

Rational service area – county, subcounty, census tracts; contiguous; similar pop. characteristics

Contiguous areas – providers not readily available in surrounding areas

Population to primary care MD ratio Must be re-designated every 4 years

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Designations for RHC Cert.

Geographic primary care HPSA – 3500:1 FTE or 3000:1 FTE for high need (FPL or wait times)

Low-income pop. HPSA – 3000:1 FTE MUA – index of FPL, Inf. Mort, > 65, pop to provider ratio, harder for rural areas

Governor’s Shortage Designation Essential community provider exception (proposed)

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Designations for RHCs - More

Each shortage designation type must be reviewed & updated every 4 years

Must reflect provider shortage Must be federally approved

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Proposed Gov’s Shortage Designation

Rational area & rural Pop. to provider ratio – 2400:1 or 2000:1 for high need

High need = above state average for FPL, > 65, unemployed, uninsured

Provide financial access (MA, MR SFS) Contiguous area not evaluated

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Gov’s Designation – Next Steps

Testing completed – 9 of 11 at-risk RHCs will meet proposed criteria

Finish Wisconsin application for new Gov’s Designation, work with Dept. and Gov’s Office to submit to HRSA

Resolve any issues with HRSA Once WI Process/criteria approved, state can request that specific area’s be designated by HRSA

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Designations & Benefits

National Health Service Corps – loan repayment ** ARRA expansion

WI Loan Assistance Program J-1 visa waiver program – foreign MDs (primary care or specialists)

Medicare 10% HPSA incentive payment Medicaid HPSA bonus for primary care

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HPSA Rule & Proposed Changes

Status 2/29/08 – Fed. Reg. MUP/HPSA Rule & revised criteria

6/2/08 – HRSA extended comment period 6/23/08 – HRSA withdrew the Rule, and is now reviewing comments and developing revisions. New Rule to be published – date tbd.

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HPSA Options for new RHCs

Check primary care HPSA status Request a new PC HPSA – provides access to more benefits than a Gov’s Designation Submit request to WI PCO:anne.dopp@dhs.wisconsin.gov

Request a Governor’s Designation

Questions?

Thank you!

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