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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 6-5 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

See Section 6.2.2 In accordance with section 503 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), federally-qualified health centers and rural health clinics (further referred to as FQHCs) will be reimbursed using an alternative payment methodology for all services provided on or after October 1, 2009.

The Department will be calculating monthly supplemental payments utilizing the Medicaid prospective payment system (PPS) rates of payment to FQHCs and information provided by the FQHC. Supplemental payments to the FQHC will be made to the FQHC through the participating CHPlus managed care organizations (MCO). Supplemental payments will be made for only claims paid and/or approved by the MCOs and/or their subcontracted Independent Practice Associations (IPAs).

In order to qualify for and receive supplemental payments for services provided to CHPlus enrollees, each FQHC must have approved PPS rates in effect for the time period and site where services were provided to a MCO enrollee; have an executed contract with the MCO, or an IPA that contracts with the MCO, for the time period; and must have received, in the aggregate, MCO payments for services rendered that are less than the FQHC would have received for those same services under the appropriate PPS Medicaid rates.

FQHCs are required to bill MCOs for all encounters for which a supplemental payment is being requested. MCOs will make payments on those claims based on their current contract or approve those claims in cases where a capitated arrangement exists between both parties. This information must be maintained and reported to the Department to ensure that the State is only making payment for an approved service that was properly billed.

Based on the information reported to the Department from the FQHC, the Department will calculate the supplemental payment that is due to each FQHC for each MCO. This “supplemental payment” is the aggregate difference between what that FQHC is paid through contracts with MCOs and its specific Medicaid PPS rate accumulated for each month.

The total supplemental payments due to FQHCs will be added to the appropriate MCO’s monthly voucher for their CHPlus enrollees. The MCO will pay the FQHC the supplemental payment no later than the end of the month they receive payment on their voucher.

The Department will compare information received from the FQHCs to the encounter data submitted by the MCOs, reconcile any material differences and adjust the supplemental payments accordingly.

6.2.6.

Prescription drugs (Section 2110(a)(6))

Scope of Coverage: Prescription medications must be authorized by a professional licensed to write prescriptions.

Level of Coverage: Prescriptions must be medically necessary. May be limited to generic medications where medically acceptable. Includes family planning or contraceptive medications or devices. All medications used for