§ 40-8-26. Community health centers.
(a) For the purposes of this section, the term community health centers refers to federally
qualified health centers and rural health centers.
(b) To support the ability of community health centers to provide high-quality medical
care to patients, the executive office of health and human services ("executive office�)
may adopt and implement an alternative payment methodology (APM) for determining a
Medicaid per-visit reimbursement for community health centers that is compliant with
the prospective payment system (PPS) provided for in the Medicare, Medicaid, and SCHIP
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§ 40-8-26. Community health centers.
(a) For the purposes of this section, the term community health centers refers to federally
qualified health centers and rural health centers.
(b) To support the ability of community health centers to provide high-quality medical
care to patients, the executive office of health and human services ("executive office�)
may adopt and implement an alternative payment methodology (APM) for determining a
Medicaid per-visit reimbursement for community health centers that is compliant with
the prospective payment system (PPS) provided for in the Medicare, Medicaid, and SCHIP
Benefits Improvement and Protection Act of 2000. The following principles are to ensure
that the APM PPS rate determination methodology is part of the executive office overall
value purchasing approach. For community health centers that do not agree to the principles
of reimbursement that reflect the APM PPS, EOHHS shall reimburse such community health
centers at the federal PPS rate, as required per section 1902(bb)(3) of the Social
Security Act, 42 U.S.C. § 1396a(bb)(3). For community health centers that are reimbursed at the federal PPS rate, subsections
(d) through (f) of this section apply.
(c) The APM PPS rate determination methodology will (i) Fairly recognize the reasonable
costs of providing services. Recognized reasonable costs will be those appropriate
for the organization, management, and direct provision of services and (ii) Provide
assurances to the executive office that services are provided in an effective and
efficient manner, consistent with industry standards. Except for demonstrated cause
and at the discretion of the executive office, the maximum reimbursement rate for
a service (e.g., medical, dental) provided by an individual community health center
shall not exceed one hundred twenty-five percent (125%) of the median rate for all
community health centers within Rhode Island.
(d) Community health centers will cooperate fully and timely with reporting requirements
established by the executive office.
(e) Reimbursement rates established through this methodology shall be incorporated into
the PPS reconciliation for services provided to Medicaid-eligible persons who are
enrolled in a health plan on the date of service. Monthly payments by the executive
office related to PPS for persons enrolled in a health plan shall be made directly
to the community health centers.
(f) Reimbursement rates established through this methodology shall be incorporated into
the actuarially certified capitation rates paid to a health plan. The health plan
shall be responsible for paying the full amount of the reimbursement rate to the community
health center for each service eligible for reimbursement under the Medicare, Medicaid,
and SCHIP Benefits Improvement and Protection Act of 2000. If the health plan has
an alternative payment arrangement with the community health center the health plan
may establish a PPS reconciliation process for eligible services and make monthly
payments related to PPS for persons enrolled in the health plan on the date of service.
The executive office will review, at least annually, the Medicaid reimbursement rates
and reconciliation methodology used by the health plans for community health centers
to ensure payments to each are made in compliance with the Medicare, Medicaid, and
SCHIP Benefits Improvement and Protection Act of 2000.