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PDFWAC 182-549-1450

Rural health clinicsGeneral payment information.

(1) The medicaid agency pays for one encounter, per client, per day except in the following circumstances:
(a) The visits occur with different health care professionals with different specialties; or
(b) There are separate visits with unrelated diagnoses.
(2) Rural health clinic (RHC) services and supplies incidental to the provider's services are included in the encounter rate payment.
(3) The agency pays for non-RHC services provided in an RHC on a fee-for-service basis using the agency's published fee schedules. Non-RHC services are subject to the coverage guidelines and limitations listed in chapters 182-500 through 182-557 WAC.
(4) For clients enrolled with a managed care organization (MCO), that MCO pays for covered RHC services.
(5) For clients enrolled with MCOs, the RHC receives an encounter rate using either the method described in (a) or (b) of this subsection.
(a) RHCs receive an enhancement payment in addition to the MCO's negotiated payment. The agency makes enhancement payments in amounts necessary to make sure that the RHC receives the full encounter rate to comply with 42 U.S.C. 1396a (bb)(5)(A).
(i) The RHCs receive a monthly enhancement payment for each managed care client assigned to them by an MCO.
(ii) To make sure that each RHC receives the appropriate amounts, the agency performs an annual reconciliation of the enhancement payments. For each RHC, the agency compares the amount paid in enhancement payments to the amount determined by the following formula: (Managed care encounters times encounter rate) less actual MCO payments for RHC services. If the RHC has been overpaid, the agency recoups the appropriate amount. If the RHC has been underpaid, the agency pays the difference. For dates of service on and after January 1, 2018, reconciliations are conducted in the calendar year following the calendar year for which the enhancements were paid. Reconciliations are conducted by the agency or the clinic with final review and approval by the agency. The process of settling over or under payments may extend beyond the calendar year in which the reconciliations were conducted.
(b) Effective January 1, 2018, instead of distributing monthly enhancement payments to the RHCs, MCOs pay the full encounter rate directly to participating clinics for encounter-eligible services.
(i) RHC participation in this option is voluntary. The RHC must notify the agency in writing whether it will participate or not by no later than November 1st prior to the year of participation.
(ii) The agency performs a reconciliation with the MCO as outlined in the MCO contract. Reconciliations make sure appropriate amounts are paid to each RHC and that MCOs are not put at risk for, or have any right to, the enhancement portion of the claim. If an MCO has been overpaid, the agency recoups the appropriate amount. If an MCO has been underpaid, the agency pays the difference.
(iii) RHCs participating in the revised alternative payment method (APM) as described in WAC 182-549-1400(8) are not eligible to receive encounter payments directly from MCOs under this section.
(6) Only those services provided to clients enrolled in the Title XIX (medicaid) program or the Title XXI (CHIP) program are eligible for encounter or enhancement payments. The agency does not pay the encounter rate or the enhancement rate for services provided to clients in state-only medical programs. Services provided to clients in state-only medical programs are considered fee-for-service, regardless of the type of service performed.
[Statutory Authority: RCW 41.05.021, 41.05.160; 42 U.S.C. 1396a (bb)(5)(A). WSR 20-24-083, § 182-549-1450, filed 11/25/20, effective 1/1/21. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-02-070, § 182-549-1450, filed 12/26/19, effective 1/26/20. Statutory Authority: RCW 41.05.021, 41.05.160, 2017 3rd sp.s. c 1 § 213(1)(ll). WSR 17-22-070, § 182-549-1450, filed 10/27/17, effective 1/1/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-12-016, § 182-549-1450, filed 5/30/17, effective 7/1/17.]
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