HRS § 346-53.64 - Federally qualified health center or rural health clinic visit
AI-assisted research summary: Some clinic services qualify for prospective payment only if they meet listed service and patient conditions; Medicaid generally pays no more than one visit per day, with stated exceptions, and certain prenatal/delivery/postnatal services may be billed globally or separately in limited ways.
(a) Services eligible for prospective payment system reimbursement are those services that are furnished by a federally qualified health center or rural health clinic that are: (1) Within the legal authority of a federally qualified health center to deliver, as defined in section 1905 of the Social Security Act; (2) Actually provided by the federally qualified health center, either directly or under arrangements; (3) Covered benefits under the medicaid program, as defined in section 4231 of the State Medicaid Manual and the Hawaii medicaid state plan; (4) Provided to a recipient eligible for medicaid benefits; (5) Delivered exclusively by health care professionals, including physicians, physician's assistants, nurse practitioners, nurse midwives, clinical social workers, clinical psychologists, and other persons acting within the lawful scope of their license or certificate to provide services; (6) Provided at the federally qualified health center's practice site, a hospital emergency room, in an inpatient setting, at the patient's place of residence, including long term care facilities, or at another medical facility; and (7) Within the scope of services provided by the State under its fee-for-service medicaid program and its medicaid managed care program, on and after August 1994, and as amended from time to time. (b) Contacts with one or more health professionals and multiple contacts with the same health professional that take place on the same day and at a single location constitute a single encounter, except when one of the following conditions exists: (1) After the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment; or (2) The patient makes one or more visits for other services such as dental or behavioral health. Medicaid may pay for a maximum of one visit per day for each of these services in addition to one medical visit. (c) A federally qualified health center or rural health clinic that provides prenatal services, delivery services, and postnatal services may elect to bill the managed care organization for all such services on a global payment basis. Alternatively, it may bill for prenatal and postnatal services separately from delivery services and be paid the per visit prospective payment system reimbursement for prenatal and postnatal visits. In this case, it may bill the managed care organization separately for inpatient delivery services that are not eligible for prospective payment system reimbursement. [L Sp 2008, c 8, pt of §2; am L 2015, c 20, §4] Note Section effective upon approval of the Hawaii medicaid state plan by the Centers for Medicare and Medicaid Services. L Sp 2008, c 8, §9. L Sp 2008, c 8, §5 provides: "SECTION 5. The department of health may provide resources to nonprofit, community-based health care providers for direct medical care for the uninsured, including: (1) Primary medical; (2) Dental; (3) Behavioral health care; and (4) Ancillary services, including: (A) Education; (B) Follow-up; (C) Outreach; and (D) Pharmacy services. Distribution of funds may be on a "per-visit" basis, taking into consideration need on all islands."