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Presents CMS-RHC Proposed Regulations : Winter 2008 Update

Presents CMS-RHC Proposed Regulations : Winter 2008 Update. Presented by Steve Rousso & Bill Deane December 3, 2008. History of RHC Regs. Rural Health Clinic Services Act of 1977 “Grandfather Clause” for RHC’s Current Legislation – June 2008 Proposed Removed Grandfather clause

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Presents CMS-RHC Proposed Regulations : Winter 2008 Update

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  1. Presents CMS-RHC Proposed Regulations:Winter 2008 Update Presented by Steve Rousso & Bill Deane December 3, 2008

  2. History of RHC Regs • Rural Health Clinic Services Act of 1977 • “Grandfather Clause” for RHC’s • Current Legislation – June 2008 Proposed • Removed Grandfather clause • Why? numbers and access and MUA’s • 1992 – 1,000 RHC’s • 2008 – 3,700 RHC’s (approx. 256 in CA) • Any questions? • Current regulations amend grandfather clause - its all about this!

  3. Shortage Designation • If you are not underserved, then you are undeserved! • Steven Rousso - 1995

  4. Location Change • Major Areas of RHC Change • Location Requirements • HPSA • MUA • Urbanized Area

  5. Review of Terms • Urbanized area – you don’t want this! • Hanford, Exeter, Madera, Porterville • “Urban Cluster” – you might as well be in a chocolate cluster! • “Non-Urbanized area”: • Nothing else matters! • HPSA • MUA • MUP • GDA – Governor Designated (not in CA)

  6. Location Requirements • Urbanized or Non-Urbanized – that is the question! • Only the Census Bureau knows for sure – it’s their maps • CMS doesn’t even know – incorrect software • Non-urbanized or not part of an urbanized area • RUCA (Level 4) won’t matter if you can’t meet 51% rule • Bottom Line: more CA communities becoming urbanized! • If the service area is now urbanized (UA) - Good night and good luck! I can’t even help you! • 51% rule is a total joke, only way around it (my opinion only) would be to limit admissions (51% or more) from non-urbanized areas.

  7. The Other Items • (QAPI) Requirements • Clarify policies on commingling • Revise Medicare payment method – not good • Revise payment to SNF’s • Allow RHC’s to contract for non-physician providers • Update waiver for mid-levels • Maintain and document infection control

  8. The Other Items • Post RHC hours for clinical services • Update requirement under the emergency services & equipment • Maintain & sign medical records • Solicit comments on payments for high cost drugs • Solicit comments on inclusion of mental health services • And whatever else that doesn’t make sense!

  9. Essential to Who? • Essential provider - came about due to elimination of grandfather clause - only if you were “essential” • Either used for clinics that are no longer HPSA or are no longer Non-Urbanized • If the clinic has lost both – no recourse to retain RHC? • Guess you are not that essential!

  10. Essential Provider Status • 4 Types: • Sole community provider(*) • Major Provider • Specialty Provider(*) • Extremely Rural Provider • Extremely Stupid Provider • *Must be more than 25 miles away or greater than 30 minutes travel time from next provider

  11. Essential Provider Status • Sole Community Provider: • self explanatory – you’re the only one providing primary care services in your service area (only RHC or FQHC). • Conclusion: • Very few can apply for this! Always another clinic around.

  12. Essential Provider Status • Extremely Rural Community Provider: defined as a frontier county or a RUCA 10 or greater and accepting Medicare/Medi-Cal, low income and uninsured patients. • CA-OSHPD defines which counties are frontier (11 or less people per square mile) • Conclusion: will apply to only a few clinics in CA – think Inyo County.

  13. Essential Provider Status • Major Community Provider: defined as provider who is actively seeing a “major share” of the area low income population. • What’s major share? >51% of patients are Medicare + Medi-Cal + uninsured • or, >31% are Medi-Cal + Uninsured • Conclusion: no stated distance to next provider requirement. Perhaps only viable option.

  14. Essential Provider Status • Specialty clinic = exclusively • OB/GYN or Pediatrics • Must accept Medicare & Medi-Cal • Patient total = > 31% “low income” • Must be “sole or major” source of services in your community • Conclusion: Very few can apply for this either!

  15. Essential Provider Status Conclusions: • Major Community provider may be only viable option. • Is there an FQHC in your area? • Don’t depend on this Status as your strategy! • Retain/Obtain a HPSA Designation!

  16. How Do I keep My HPSA • Health Care Safety Net Act of 2008 – was signed and permits designations to last 4 years • Renew existing HPSA every 3 years • Options in HPSA Types: • Geographic • Low Income/Special Population • Combining MSSA’s (neighboring service areas) • County Wide – but, distance & population limitations • Medi-Cal Claims (non-managed care counties) • Use of Migrant, Tourist and Seasonal Populations • Denominator and Numerator exercise

  17. A HPSA/Location Problem • Sonoma County – Part urbanized, part non-urbanized • Healdsburg (205.1) is Rural, • Windsor (205.2) next door is Urbanized • Windsor is 10 minutes drive time, Santa Rosa is 20 minutes drive time (What time of day is that? ) • Is Healdsburg an Essential Provider? Clue: not a HPSA!

  18. Location Exception Process • Submit HPSA application within 3 year renewal period OR HRSA begins the decertification process. • If no HPSA, submit “location exception” application within 90 days of end of 3 year HPSA period. • HRSA will decertify an RHC 180 days “after • the date the RHC no longer met the location requirements”… (BIG change from 2003 proposed regs – CMS would notify clinic of a potential problem) • Additional 120 day extension available for provider-based RHCs.

  19. Oh Yeah, the Other Items • MAJOR PROVISIONS • Mid-Level Waiver • Employment of Mid-Levels • Payment requirements • QAPI • Commingling

  20. Mid-Level Waiver Update Waiver for Mid-levels: • CMS will grant a 1 year waiver for RHCs operating without a mid-level, as long as the RHC can demonstrate that they have made a “good faith effort” to obtain one. • Existing only – not new providers • A few extensions, then decertification, what else is new?

  21. Employment of Midlevels • One is good • 50% rule • Good for physician salary negotiations • FQHC’s always have been allowed to contract for mid-levels

  22. Proposed RHC Payments • CMS currently pays RHC’s 80% of “reasonable costs” • Now, CMS to pay RHC’s 80% minus beneficiary co-insurance & deductibles • Exception to payment limit for provider-based RHC’s if hospital <50 beds AND located in RUCA 9 or 10 • Bottom Line – CMS wants to redefine “reasonable costs”? Isn’t that clear through costs reports?

  23. QAPI Requirements • Implementation of an Assessment program more data-driven than existing annual evaluation • Require FQHC’s & RHC’s to document infection control process • RHC’s to post hours of operation • Update physical plant and equipment to include compliance with infection control • Update patient medical records – must be complete, notated, dated and authenticated by M.D. within 48 hours.

  24. Commingling • Distinguishes RHC versus non-RHC space • Basically illegal in RHC space to conduct most non-RHC business

  25. Questions and Answers ANY QUESTIONS? Thank You!

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