NARHC Technical Assistance CallNARHC Technical Assistance CallJuly 8, 2008July 8, 2008

CMS 1910 P2:Medicare Program; Changes in Conditions of Participation Requirements and Payment Provisions for Rural Health Clinics and Federally Qualified Health Centers: Proposed Rule

NARHC Technical Assistance CallNARHC Technical Assistance CallJuly 8, 2008July 8, 2008

CAPT Corinne Axelrod, MPH, LAc, Dipl.Ac

Centers for Medicare & Medicaid Services (CMS)

Center for Medicare Management (CMM)Hospital and Ambulatory Policy Group (HAPG)Division of Ambulatory Services (DAS)410-786-5620corinne.axelrod@cms.hhs.gov

AgendaAgenda

I. Background II. Highlights of the Proposed RuleIII. RHC Location RequirementsIV. Proposed RHC Location

Exception Criteria

I. Background:I. Background:Rural Health Clinic Services Act Rural Health Clinic Services Act

of 1977of 1977– Amended the SSA by adding Sec.1861(aa) to

extend Medicare and Medicaid entitlement and payment for primary and emergency care services furnished at an RHC by physicians, NPs, and PAs, for services and supplies incidental to their services

- Authorized CMS and States to pay qualifying clinics on a cost-related basis for these services

- Required that clinics be located in an area that is designated by the Census Bureau as non-urbanized, and designated or certified by HRSA as a shortage area. Contained a “grandfather” clause that enabled an RHC to remain in the program even if it no longer met the location requirements

Background:Background:

Balanced Budget Act (BBABalanced Budget Act (BBA)) of 1997 of 1997

• Amended Section 1861(aa)(2) of the SSA to apply location requirements to new and existing RHCs and permit exceptions to the location requirements for an existing RHC if the RHC can show that it is essential to the delivery of primary care in the service area (removed the “grandfather” clause)

Background: Background: Regulations to Implement BBA Regulations to Implement BBA

ChangesChanges

February 2000 - Proposed Rule (P1)December 2003 - Final Rule 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)

II. Highlights of the Proposed II. Highlights of the Proposed RuleRule

The proposed rule would:

• Implement location requirements of the BBA and establish exception criteria for existing RHCs

• Allow RHCs to contract with RHC non-physician providers under certain circumstances

• Create a one year staffing waiver for existing RHCs

Highlights of the Proposed RuleHighlights of the Proposed Rule

• Revise the RHC and FQHC payment methodology

• Clarify “commingling” policies

• Require RHCs to establish a Quality Assessment and Performance Improvement Program (QAPI)

Highlights of the Proposed RuleHighlights of the Proposed Rule

• Solicit comments on high cost drugs

• Propose other changes to update the regulations to clarify existing requirements, provide the opportunity to make program improvements, and comply with statutory requirements

Highlights of the Proposed RuleHighlights of the Proposed Rule

• Use RUCAs (Rural Urban Commuting Areas) instead of UICs (Urban Influence Codes)

- more precise measurement of rurality- consistent with other CMS programs (e.g. hospital and ambulance payment systems)

How to Determine the RUCA for How to Determine the RUCA for Your AreaYour Area

By zip code - http://depts.washington.edu/uwruca/data.html

By census tract -http://www.ers.usda.gov/briefing/Rurality/RuralUrbanCommutingAreas/

To find out your census tract: http://www.ffiec.gov/Geocode/default.aspx)

III. RHC Location III. RHC Location RequirementsRequirements

Two Location Requirements

1. The RHC must be in a non-urbanized area, as defined by the U.S. Census Bureau, and

2. The RHC must be in an area that has been designated or certified by the Secretary within the previous 3 years as having an insufficient number or needed health care practitioners

Requirement #1 - U.S. Census Requirement #1 - U.S. Census Bureau Bureau

Non-Urbanized AreaNon-Urbanized Area Urbanized Area (UA) - An area consisting of a central place(s) and

adjacent territory with a general population density of at least 1,000 people per square mile of land area that together have a minimum residential population of at least 50,000 people

– Does NOT meet this RHC location requirement

Urban Cluster (UC)- A densely settled territory that has at least 2,500

people but fewer than 50,000- Meets this RHC location requirement

Neither a UA nor a UC- Meets this location requirement

How to Determine if Your RHC is How to Determine if Your RHC is in a Non-urbanized Areain a Non-urbanized Area

Go to http://factfinder.census.govTool bar on top -- Select “Search”Tool bar on top -- Select “Geography”Select the option --“Show More Selection

Methods” Select – “Address Search”Enter address and zip code, hit “go”Scroll down below county, below congressional

district, below metropolitan statistical area, above the 3 digit zip code tabulation

If a UA or UC, it will say: Urban Area: (Town) (State) followed by (Urbanized Area OR Urbanized Cluster)

What to Do if Your RHC is Located in What to Do if Your RHC is Located in an Urbanized Area (UA)an Urbanized Area (UA)

• If the RHC is in a UA and meets the eligibility criteria for an exception, submit an application to be considered an Essential Provider within 90 days from the effective date of the final rule to the appropriate Regional Office

Essential ProviderEssential Provider

• An RHC that does not meet one of the location requirements may be considered an Essential Provider if primary care services would otherwise be unavailable in the geographic area served by the clinic

Eligibility Criteria for UA Location Eligibility Criteria for UA Location ExceptionException

To apply for this exception, the RHC must • Be in a level 4 or higher RUCA, and• Demonstrate that at least 51% of its patients

reside in an adjacent non-urbanized area, and • Have a current shortage area designation

Questions?Questions?

Questions on the Urbanized Area

Requirement?

Requirement #2 - Requirement #2 - Designated/Certified AreasDesignated/Certified Areas

The RHC must be in an area that has been designated or certified by the Secretary within the previous 3 years as having an insufficient number of needed health care practitioners

Designation ApplicationsDesignation Applications

Designation applications are usually prepared by the State (not the RHC)

List of State Primary Care Offices available at:http://hrsa.gov/grants

Designation applications are submitted to HRSAhttp://bhpr.hrsa.gov/shortage/hpsapply.htm

Designation Types Acceptable for Designation Types Acceptable for this RHC Location Requirementthis RHC Location Requirement

4 types of designations satisfy this RHC location requirement:

• Geographic Health Professional Shortage Area (HPSA)

• Population-group HPSA• Medically Underserved Area (MUA)• Governor-designated and Secretary-

Certified (GDSC) Shortage Area

Designation Types NOT Designation Types NOT Acceptable for RHC Location Acceptable for RHC Location

RequirementsRequirements

Designations NOT ACCEPTABLE:• Medically Underserved Population

designations (MUP)• Automatic HPSA designations• Safety-net facility designations• Dental or mental health HPSA

designations• State designations (different from the

GDSC designation)• Any others that are not among the 4

acceptable designations

How to Determine if Your RHC is How to Determine if Your RHC is in a Designated in a Designated HPSAHPSA (Geo or (Geo or

Pop)Pop)

• Go to http://hpsafind.hrsa.gov• Above the blue boxed area, click on

“Advanced Search by…”• Select “State”, “County”, and

“Primary Care”• Under “Metro”, select “All”• Under “Status”, select “Designated”• Under ‘Types”, select “Geographic

Single County and Service Area” and “Population Groups”

HPSA ScreenHPSA Screen

• HPSA name • Parts included in the designation

(whole county, townships, census tracts, etc.)

• HPSA identification number• Status (designated)• Type (geographic, population group,

etc.)• FTE• Degree of shortage• Score• Date of the last update

How to Determine if Your RHC is How to Determine if Your RHC is in a Designated in a Designated MUAMUA

1. Go to: http://muafind.hrsa.gov

2. Select your state and county, then “Find MUAs/MUPs”

How to Determine if Your RHC is How to Determine if Your RHC is in a in a GDSCGDSC Shortage Area Shortage Area

Governor-designated and Secretary-Certified Shortage Area

Call HRSA’s Shortage Designation Branch 301-594-0816

HRSA’s Proposed RuleHRSA’s Proposed Rule

• Proposes changes to the methodology to determine designations

• Does not affect the requirement that an RHC be in a designated area

• Tier I and Tier II designations will be accepted

• More RHCs are in areas that retain their designation under the proposed method than the current method

• When finalized, many areas will be automatically designated (no application needed)

What to Do if Your RHC is Not in What to Do if Your RHC is Not in a Currently Designated Areaa Currently Designated Area

• Contact your State Primary Care Office to determine if an application to update the designation of the RHC’s area has been submitted

• If HRSA has received a designation application (new or update) for the area where the RHC is located before the end of the 3 year period since the last designation, no action needed

When to Apply for an Exception to When to Apply for an Exception to this Location Requirementthis Location Requirement

If the RHC is not in a UA and

1) HRSA has not received an application to designate or update the area before the end of the 3 year period, or

2) HRSA received an application to update the designation but determined that the area no longer qualifies for one of the designation types accepted for RHC certification

When to Apply for An Exception to When to Apply for An Exception to This Location RequirementThis Location Requirement

• Submit an application for an exception to the appropriate Regional Office within 90 days from the date the designation is no longer current or within 90 days of the effective date of the regulation, whichever is later

• RO’s have 90 days to review the application for an exception to the location requirements

• Denial of exception request can be appealed per Part 498.3(b)(5)

DecertificationDecertification

• RHCs are protected from decertification if HRSA has received an application to update the designation before the end of the 3 year period

• A clinic that is decertified as an RHC may apply to become another type of Medicare provider who would then bill Medicare using the fee for service system

DecertificationDecertification

• Decertification would be effective on the last day of the month in which the 180 day limit was met

• Advantageous for an RHC to submit their request for an exception as soon as possible for planning purpose

DecertificationDecertification

• A provider-based clinic that does not meet the location requirements and does not qualify for an exception and has submitted to CMS an application to be another type of Medicare provider that requires a state survey for certification would have a 120 day extension of their status as an RHC while their application is being processed

Example #1Example #1

• RHC located in area designated as a geographic primary care HPSA on 1/2/06

• Deadline for application to HRSA to update the designation for RHC certification is 1/2/09

• Scenario 1 – Application received by HRSA before 1/2/09, application approved, area’s designation is updated, no action necessary by the RHC for 3 years from the date of the designation update.

Example #2Example #2

• Scenario 2 – Application to update the designation is not submitted to HRSA by 1/2/09. RHC has until 4/2/09 (90 days) to submit request to the RO for an exception

• RHC does not submit application for an exception to RO by 4/2/09

• RHC is decertified July 31, 2009

Example #3Example #3

• Scenario 3 – Application to update the designation is not submitted to HRSA by 1/2/09. RHC has until 4/2/09 (90 days) to submit request to the RO for an exception

• RHC submits exception application to RO by 4/2/09

• RO has up to 90 to review the exception application and make a determination

• RO approves the exception, no action needed for 3 years from the date of notification.

Example #4Example #4

• Scenario 4 – Application to update the designation is not submitted to HRSA by 1/2/09. RHC has until 4/2/09 (90 days) to submit request to the RO for an exception

• RHC submits exception application to RO by 4/2/09

• RO has up to 90 to review the exception application and make a determination

• RO disapproves the exception request, RHC is decertified 90 days from the date of notification, effective the last day of the month

Questions?Questions?

Questions on the Designation Requirement?

IV. Proposed RHC LocationIV. Proposed RHC Location Exception Criteria Exception Criteria

• Sole Community Provider• Major Community Provider• Specialty Clinic• Extremely Rural Community

Provider

Exceptions CriteriaExceptions Criteria

• “Participating primary care provider” means another RHC, FQHC, or primary care provider that is actively accepting and treating Medicare beneficiaries, Medicaid recipients, low‑income patients, and the uninsured (regardless of their ability to pay)

Sole Community ProviderSole Community Provider

The RHC meets either of the following requirements:

• The RHC is at least 25 miles from the nearest participating primary care provider; or

• The RHC is at least15 miles but less than 25 miles from the nearest participating primary care provider and can demonstrate that it is more than 30 minutes from the nearest primary care provider based on local topography, predictable weather conditions, or posted speed limits

Major Community ProviderMajor Community Provider

The RHC meets both the following requirements:

• Has a Medicare, Medicaid, low-income, and uninsured patient utilization rate greater than or equal to 51 percent, or a low-income patient utilization rate greater than or equal to 31 percent; and

• Is actively accepting and treating a major share of Medicare, Medicaid, low-income and uninsured patients (regardless of their ability to pay) compared to other participating primary care providers that are within 25 miles of the RHC.

Specialty Clinic: Specialty Clinic: Obstetrics/Gynecology (Ob/Gyn) Obstetrics/Gynecology (Ob/Gyn)

or Pediatricsor Pediatrics The RHC meets all of the following

requirements:• Exclusively provides ob/gyn or pediatric

health services (as applicable) and• Is actively accepting and treating

Medicare, Medicaid, low-income, and uninsured patients and

• Has a Medicare, Medicaid, low-income patient and uninsured utilization rate greater than or equal to 31 percent, and

• Provides ob/gyn (including prenatal care) or pediatrics services onsite to clinic patients, and

Specialty Clinic: Specialty Clinic: Obstetrics/Gynecology (Ob/Gyn) Obstetrics/Gynecology (Ob/Gyn)

or Pediatricsor Pediatrics• Is the sole or major source of ob/gyn or

pediatrics for Medicare (where applicable), Medicaid, and uninsured patients (regardless of their ability to pay) and is either of the following:- At least 25 miles from the nearest participating provider of ob/gyn or pediatric services or

- At least 15 miles but less than 25 miles from the nearest participating provider of ob/gyn or pediatric services, and can demonstrate that it is more than 30 minutes from the nearest participating primary care provider providing these services based on local topography, predictable weather conditions, or posted speed limits

Extremely Rural Community Extremely Rural Community ProviderProvider

The RHC meets both the following requirements:

• Is located in a frontier county (6 or less persons per square mile) or in a RUCA code 10, and

• Is actively accepting and treating Medicare, Medicaid, low-income, and uninsured patients (regardless of their ability to pay)

Mental Health Specialty Mental Health Specialty ClinicsClinics

• Was included in the 2003 Final Rule as a Specialty Clinic

• Statute prohibits an RHC from being a facility which is primarily for the care and treatment of mental diseases

Mental Health Specialty Clinics Mental Health Specialty Clinics

• Since the statute imposes a “ceiling” on mental health services, is it still appropriate to include RHCs that provide mental health services for purposes of an exception to the location requirement?

• If so, what should the minimum level of mental health services be in order to qualify for an exception?

Questions?Questions?

Questions on the Exception Criteria?

Additional InformationAdditional Information

• Next NARHC TA Call – RHC Proposed Regulation- Staffing - Payment Requirements- Health, Safety, & Quality

• Next CMS Rural Open Door Forum July 29, 2008 2:00 pm – 3:00 pm EST

• Special RHC Open Door ForumAugust 5, 2008 2:00 p.m. – 4:00 pm EST

• CMS Regional Rural Health Coordinators

RHC Final RuleRHC Final Rule

• Comment period closes 5:00 p.m. on August 26, 2008

• All comments will be addressed and considered for the Final Rule

• Provisions of the rule will be effective 60 days after publication of the Final Rule

Thank you!