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Wisconsin Office of Rural HealthHospital Finance Workshop
Anne [email protected]
Todd [email protected]
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.)
10
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.
11
Current RHC CoPs Program Evaluation
Must conduct comprehensive annual program evaluation
12
Payment for RHC Services
All-inclusive rate for each visit
Subject to per-visit limit Based on FI/MAC calculated cost per visit
13
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)
14
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
15
RHC Proposed Changes -CoPs and Payment Provisions
16
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
17
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?)
18
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
19
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)
21
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
22
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
23
RHC Proposed Changes In CoP (cont.)
Other Proposed Changes
QAPI program Infection control program Post hours of operation Required common emergency equipment
24
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
25
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.)
26
HPSA 101 for RHCs
Highlights from the complex world of federal shortage designation!
27
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
28
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
29
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)
30
Designations for RHCs - More
Each shortage designation type must be reviewed & updated every 4 years
Must reflect provider shortage Must be federally approved
31
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
32
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
33
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
34
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.
35
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:[email protected]
Request a Governor’s Designation
Questions?
Thank you!
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