NC Medicaid Behavioral Health I/DD Tailored Plans Federally Qualified Health Center /Rural Health Clinics PPS-APM wrap payment methodology (2024)

This bulletin applies to NC Medicaid Managed Care Behavioral Health I/DD Tailored Plans (Tailored Plans).

NOTE: Tailored Plans will implement the Federally Qualified Health Center (FQHC)/Rural Health Clinics (RHC) Prospective Payment System - Alternate Payment Methodology (PPS-APM) wrap payment reimbursem*nt methodology beginning with claims with a date of service (DOS) on or after Dec. 1, 2024, instead of Oct. 1, 2024.

This bulletin pertains to the Tailored Plans FQHC/ RHC PPS-APM wrap payment methodology. Tailored Plan FQHC/RHC reimbursem*nt methodology changes have been revised to begin with dates of service on or after Dec. 1, 2024.

The Centers for Medicare & Medicaid Services (CMS) approved State Plan Amendments (SPAs) SPA 23-0021 for Rural Health Clinics and SPA 23-0022 for Federally Qualified Health Centers to amend Attachment 4.19-B, Section 2 to revise the reimbursem*nt methodology for FQHC and RHC providers.

The effective date for each SPA is July 1, 2023, and has been implemented with Standard Plans and NC Medicaid Direct. The target date for operationalizing the SPA changes for Tailored Plans is Dec. 1, 2024.

For Tailored Plan encounters paid to FQHC / RHC providers with dates of service between Tailored Plan launch date of July 1, 2024, and Nov. 30, 2024, the Department will perform a reconciliation and make a lump sum payment to each FQHC and RHC provider equal to the difference between what each FQHC/RHC provider would have received under the PPS-APM methodology and actual payments received.

The new methodology for FQHC and RHC provider types encompasses several key changes:

1. The methodology establishes a new provider-specific PPS-APM rate for Core Service, Well Child and Dental visits based on 113% of Medicaid Allowable Costs from the provider’s 2021 Medicaid Cost Reports.
2. The resulting PPS-APM rate is inflated to the current period by the greater of the FQHC Market Basket or the Consumer Price Index (CPI) for medical care.
3. The PPS APM rate will be rebased triennially based on Medicaid Cost Reports.

The new methodology will be operationalized in the following manner:

NC Medicaid Managed Care Tailored Plan

• New - Providers will be reimbursed statewide base rates by Tailored Plans for Core Services (T1015) and Well Child Visit (99381EP-99385EP; 99391EP-99395EP) covered services. The base rates are as follows:
  • T1015 for FQHCs $117.32
  • T1015 for RHCs $83.30
  • Well Child for FQHC/RHC $80.33
• Providers will continue to bill and be reimbursed by the Tailored Plans for the following ancillary covered services based on the applicable codes on the FQHC/RHC Medicaid Fee Schedules:
  • Diagnostic Laboratory Services
  • Physician Hospital Services
  • Pharmacy Services
  • Incentive Payments
• New - FQHC or RHC physician-professional services performed in a hospital inpatient or outpatient setting billed under the FQHC or RHC taxonomy and the hospital place of service are separately reimbursable by the Tailored Plans under the Physician Services Fee Schedule.
• New - FQHC or RHC physician-professional services that are not performed in a hospital inpatient or outpatient setting and billed under the FQHC or RHC taxonomy and non-hospital place of service are not separately reimbursable and will be reimbursed under the FQHC/RHC PPS rate.
• New - Providers will continue to bill all other ancillary services rendered for covered FQHC/RHC services; however, these ancillary services will be set to reimburse zero based on the NC Medicaid Fee Schedule. The reimbursem*nt for these services has been factored into the grossed-up PPS-APM rate paid on Core Service, Well Child and Dental encounters. It is important for the triennial rebase of Medicaid Allowable Cost for providers to continue to bill these covered ancillary services to the Tailored Plans.
• New - Simultaneously with the paid T1015 and Well Child base rates, Tailored Plans are expected to reimburse FQHC/RHC providers a wrap payment equal to the difference between the provider specific PPS-APM rate and the base rate.
• New – For NC Medicaid Managed Care: Since the intended date for Tailored Plans to operationalize the above changes is Dec. 1, 2024, FQHC/RHC providers will continue to be reimbursed under existing methodology through Nov. 30, 2024. For the period between July 1, 2024, through Nov. 30, 2024, the Department will calculate and make a lump sum payment to each FQHC / RHC provider equal to the difference between what each provider would have received under the PPS-APM rate methodology for the same services and the actual fee-for-service payments received.
• Note: NC Medicaid Tailored Plans will not be required to reprocess claims.

Fee Schedules

The Department will be updating the FQHC/RHC Fee Schedules. The fee schedules’ effective date of July 1, 2024, reflects the State’s approval of the new Alternative Payment Methodology (APM) rates for the State Fiscal Year beginning July 1, 2024. However, Tailored Plans will begin to reimburse the APM rate for claims with a DOS on or after Dec. 1, 2024, using the following fee schedules:

• New - NC Medicaid Managed Care Fee Schedules:
  • MC RHC PPS-APM - Well Child Fee Schedule
  • MC FQHC PPS-APM – Well Child Fee Schedule
  • MC FQHC Physician Services
  • MC RHC Physician Services
• The following fee schedules will be archived for Tailored Plans as of Nov. 30, 2024:
  • Federally Qualified Health Centers
  • Rural Health Center
  • Federally Qualified Health Centers Core Service
  • Rural Health Center Core Service
• Note: Providers that have not delivered the data required for rate determinations will be assigned rates based on the SPA rate methodology guidelines.

Billing and Encounter Data Guidance Updates

The new FQHC/RHC wrap payment methodology resulted in updates to the Encounter Data Submission Guide section 3.2.4, and the Health Plan Billing Guidance sections 3.8.1 and 3.8.2. Providers should work with the Tailored Plan(s) with which the provider has contracted to gather more detail regarding these updates as well as any further updates in subsequent Billing Guide versions.

Contact

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• Behavioral Health Providers

• Division of Health Benefits