Cenevia supports DMAS’s efforts to issue a written FQHC Medicaid change in scope policy to support health center efforts to seek rate adjustments.

The proposed Policy appropriately acknowledges that changes in the “type, intensity, duration or amount of services” may trigger changes in scope consistent with CMS guidance from 2001.  The list of qualifying events for a possible change in scope should include language explicitly stating that the list is provided by way of example and meant to be non-exhaustive. The example stating that a qualifying event includes “a change in intensity, type, or duration of a service resulting from federal or state regulatory requirements specific to FQHCs” is unduly narrow. First, the omission of “amount” of services is inconsistent with 2001 CMS guidance that includes changes in the amount of services. Second, the example provided excludes changes in intensity, type, duration, and amount of services that do not stem from explicit federal or state regulatory requirements and are simply changes stemming from improved/best practices or changes/modernizations in health services delivery.  Limiting the federal or state regulatory requirements to just those that apply specifically to FQHCs is also unduly narrow because there may be changes that apply to numerous health care provider types, not just FQHCs, that FQHCs will have to comply with.

It is unclear whether the Policy seeks to isolate only the incremental cost of the qualifying event in providing, “The change in scope may result in an increase or decrease of the Medicaid base rate, depending on the total allowable costs attributable to the change in scope.” This language appears to focus on just the incremental cost associated with the change. However, in the next paragraph the Policy provides that, “The new Medicaid PPS base rate will be calculated using the provider’s reasonable total allowable cost of furnishing core and non-core covered services divided by the total number of encounters for the change in scope year.” This language is consistent with the all inclusive rate calculation methodology contemplated by the Medicaid cost report and implicitly acknowledges the difficulty that attempting to isolate the incremental costs associated with implementing a proposed qualifying event would entail. We suggest that the Policy be revised to eliminate the language “depending on the total allowable costs attributable to the change in scope” to eliminate the possibility of an incremental approach to the rate adjustment process.  

The requirement that implementation of the qualifying event will need to take place for a full fiscal year, is mitigated somewhat by the fact that the Policy contemplates the submission of interim change in scope requests in accordance with Section 3. The other mitigating factor is that if the qualifying event is established then the approved PPS rate will be made retroactive to the date the change was implemented. That retroactivity somewhat mitigates against the length of time processing the rate adjustments will take. Both the interim request option and the retroactivity element should be considered material elements of the Policy that are retained as the Policy is finalized.  The time period to review and either approve or deny the request should be reduced from 180 to 90 days.

The Policy appropriately incorporates administrative appeal rights that are then subject to judicial review if a provider is dissatisfied.