Rule 5160-28-03 | FQHC and RHC services: covered services, limitations, and copayments.
(A) A federally qualified health center (FQHC) may receive prospective payment system (PPS) payment for providing any of the following FQHC PPS services:
(1) In accordance with section 330 of the Public Health Services Act, 42 U.S.C. chapter 6A (October 1, 2021), medical services, which comprise any of four types of services:
(a) Services referenced at 42 U.S.C. 1395x(aa)(3) (October 1, 2021), including but not limited to an evaluation and management (E&M) service, another medical or surgical procedure, or the administration of a vaccine or other provider-administered pharmaceutical;
(b) Professional services (including the administration of a vaccine) furnished by a qualified healthcare practitioner (physician, physician assistant, advanced practice registered nurse, dietitian, pharmacist, registered nurse working under supervision), along with any services or supplies furnished incident to the professional services on the same date;
(c) Professional services and related supplies provided at a later date as necessary follow-up to a medical services visit, even if the same services and supplies were also provided as part of (or incident to) the original medical services visit; or
(d) Visiting nurse services if the following three conditions are satisfied:
(i) The services are furnished by either a registered nurse or a licensed practical nurse employed by or under contract with the FQHC;
(ii) The FQHC is located in an area determined by the centers for medicare and medicaid services (CMS) to have a shortage of home health agencies; and
(iii) The services are furnished under a written plan of treatment that is established by a physician, physician assistant, or advanced practice registered nurse or by a supervising physician of the FQHC; is signed by a physician, physician assistant, or advanced practice registered nurse or by a supervising physician of the FQHC; and is reviewed at least every sixty days by a supervising physician of the FQHC.
(2) Dental services, which are identified in Chapter 5160-5 of the Administrative Code and to which the following conditions apply:
(a) An FQHC reports every dental procedure or service, in the appropriate claim format, as a PPS service; and
(b) For each set of dentures, an FQHC may submit one claim for providing the service and not more than two additional claims for follow-up visits;
(3) Physical therapy services or occupational therapy services, which are identified in Chapter 5160-8 of the Administrative Code;
(4) Behavioral health services identified in rule 5160-8-05 of the Administrative Code;
(5) Speech pathology and audiology services, which are identified in Chapter 5160-8 of the Administrative Code;
(6) Podiatry services, which are identified in Chapter 5160-7 of the Administrative Code;
(7) Vision services, which are identified in Chapter 5160-6 of the Administrative Code, that are rendered by a non-physician;
(8) Chiropractic services, which are identified in Chapter 5160-8 of the Administrative Code; or
(9) Transportation services that enable an individual to make up to four trips to or from an FQHC site (or related location) where a covered service is rendered on the same date.
(B) A rural health clinic (RHC) may receive PPS payment for providing any of the following RHC PPS services:
(1) Medical services, which comprise any of three types of services:
(a) All services referenced at 42 U.S.C. 1395x(aa)(1) (October 1, 2021), including but not limited to an evaluation and management (E&M) service, another medical or surgical procedure, or the administration of a vaccine or other provider-administered pharmaceutical;
(b) Professional services (including the administration of a vaccine) furnished by a qualified healthcare practitioner (e.g., physician, physician assistant, advanced practice registered nurse, dietitian, pharmacist, registered nurse working under supervision), along with any services or supplies furnished incident to the professional services on the same date;
(c) Professional services and related supplies provided at a later date as necessary follow-up to a medical services visit, even if the same services and supplies were also provided as part of (or incident to) the original medical services visit;
(2) Behavioral health services identified in rule 5160-8-05 of the Administrative Code; or
(3) Transportation services that enable an individual to make up to four trips to or from an RHC (or related location) where a covered service is rendered on the same date.
(C) An FQHC or RHC may structure its enrollment in medicaid such that it can submit a claim and receive separate payment for a covered service or supply that cannot be claimed as a PPS service under paragraphs (A) and (B) of this rule.
(1) No PPS service may be claimed as a non-PPS service. Payment for a covered non-PPS service is made in accordance with the rule or chapter of the Administrative Code that applies to the service.
(2) The following non-exhaustive list specifies covered medically necessary services and supplies that may be claimed as non-PPS services:
(a) Group therapy;
(b) Remote patient monitoring;
(c) Acupuncture rendered by an acupuncturist;
(d) Inpatient hospital services;
(e) Take-home medications;
(f) Hemophilia clotting factor drugs;
(g) Long-acting reversible contraception (LARC);
(h) Durable medical equipment for take-home use;
(i) The technical component of a procedure comprising both a professional and a technical component, such as radiography or other imaging;
(j) Clinical diagnostic laboratory services other than the following procedures:
(i) Venipuncture;
(ii) Chemical examination of urine by stick or tablet method or both;
(iii) Hematocrit or hemoglobin analysis;
(iv) Blood sugar analysis;
(v) Examination of stool specimens for occult blood;
(vi) Pregnancy tests; and
(vii) Primary culturing for transmittal to a certified laboratory;
(k) Eyeglass lenses and frames;
(l) Topical fluoride varnish furnished by a non-dental practitioner in accordance with rule 5160-4-33 of the Administrative Code;
(m) A vaccine administered as part of a mass immunization;
(n) A report of a pregnancy that is diagnosed in conjunction with a PPS service, described in rule 5160-21-04 of the Administrative Code;
(o) A pregnancy risk assessment, described in rule 5160-21-04 of the Administrative Code; and
(p) Behavioral health services and substance use disorder services identified in Chapter 5160-27 of the Administrative Code that meet the following criteria:
(i) They cannot be claimed as PPS services; and
(ii) They are rendered by certified behavioral health practitioners in accordance with Chapter 5160-27 of the Administrative Code and federal and state law.
(3) The provision of a covered non-PPS service on the same date as a covered PPS service does not preclude payment for either service.
(D) Copayments established in accordance with rule 5160-1-09 of the Administrative Code may apply to services rendered by an FQHC or RHC. Copayments for services rendered to MCE members are applied in accordance with applicable medicaid rules in the Administrative Code concerning MCEs.
Last updated March 25, 2024 at 9:16 AM
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