Wisconsin Office of Rural Health
Hospital Finance Workshop
Anne Dopp
anne.dopp@dhs.wisconsin.gov
Todd Nova
tnova@hallrender.com
HPSAs and RHCs: An Overview of Current Benefits, CurrentRequirements, and New Developments
August 19, 2009
Agenda
1.Current RHC conditions of participation
2.Current RHC benefits
3.CMS Proposed Rule for RHCs (including shortagedesignation requirement)
4.HPSA 101 for RHCs:
HPSA types & requirements for RHCs
HPSA linked benefits
Governor’s Shortage Designation status
3
Current RHC CoPs
Location – Rural and Underserved
Rural: Non-MSA or rural census tract
Shortage: HPSA, MUA or Governor's Shortage
HPSA Update Requirement
New RHCs: Updated in preceding 3 years
Existing RHCs: Grandfathered
4
Current RHC CoPs
Physical Plant
Preventive maintenance program (generalequip., patient care equip., drug/biologicalstored appropriately, housekeeping)
Emergency Procs. (staff training, exit signs,etc.)
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Current RHC CoPs
Organizational Structure
Medical Director
Policies and lines of authority in writing
6
Current RHC CoPs
Staffing
One or more physicians – at least once every2 weeks
Medical direction
Available for emergencies
One or more midlevels (NP, PA, CNM, CSW,Clinical Psychologist)
At least 50% of RHC working hours
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Current RHC CoPs
Staffing (cont.)
Physician and midlevel joint duties
Develop, execute and periodically review writtenpolicies and services
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Current RHC CoPs
RHC Services
Outpatient primary services – conditions which causea patient to present at a physician's office
Services commonly furnished in physician office or atsystem entry point
Consistent with written policies
Developed by "group of professional personnel" thatincludes 1+ physicians and 1+ midlevels. At least 1member NOT member of RHC staff
Reviewed at least annually
Patient care, records, drug storage, etc.
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Current RHC CoPs
RHC Direct Services
Furnished by clinic or center staff
Lab: Urinalysis, hemoglobin, glucose, occultblood, pregnancy, primary culturing,
Emergency: Common first responseprocedures and drugs (antibiotics,anticonvulsants, local anesthetics, etc.)
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Current RHC CoPs
Arrangements
Must have arrangement or agreement withMedicare or Medicaid provider to furnish
Inpatient care
Physician services
Specialized diagnostics (imaging and lab)
Records
Must maintain records system consistent withpolicies managed by designated staff person,among other requirements.
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Current RHC CoPs
Program Evaluation
Must conduct comprehensive annual programevaluation
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Payment for RHC Services
All-inclusive rate for each visit
Subject to per-visit limit
Based on FI/MAC calculated cost per visit
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Payment for RHC Services
Deductible/Coinsurance
After deductible is satisfied, RHCs paid 80% of all-inclusive rate
Patient responsible for coinsurance amount of 20%percent of charges (not per-visit rate)
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Payment for RHC Services
Exceptions to per visit limit
Provider based to hospitals
With < 50 beds
Average daily census < 41 AND both:
SCH
UIC level 8 or 9
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RHC Proposed Changes -CoPs and Payment Provisions
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RHC Proposed CoP Changes
Status
February 28, 2000 – Proposed Rule
December 24, 2003 – Final Rule
September 22, 2006 – Suspended effectiveness ofFinal Rule
> 3 years before 2003 Rule was finalized
June 28, 2008 Proposed Rule – "Re-implementing"December 2003 Final Rule
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RHC Proposed Changes In CoP (cont.)
RHC Location Requirements: Rural and Shortage
But what if the HPSA isn't updated?
Current
Existing RHCs – grandfathered
New RHCs – tough noogies (or is it nuggies?)
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RHC Proposed Changes In CoP (cont.)
What if the HPSA isn't updated?
Proposed
Grandfather rule terminated – decertification possible
Termination automatically effective 180 days afterfailure to comply with location requirements
Would be able to avoid immediate decertification by
Submitting application to update shortage area; or
Submitting essential provider application
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RHC Proposed Changes In CoP (cont.)
Impact of Provider-Based RHC Decertification on CAHStatus
Grandfathered provider-based clinic (1/1/08) – canbe within 35 miles of another hospital
CAHs can convert existing clinic (provider-based ornot) to a provider-based RHC, CAH status notcompromised
Will decertification of that RHC jeopardize CAH?
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RHC Proposed Changes In CoP (cont.)
Proposed
If in UA or non-shortage area, canapply for one of four:
"Essential Provider Exceptions"
But First:
In Level 4 RUCA; AND
At least 51% of patients reside in non-urban area (or areadjacent thereto)
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RHC Proposed Changes In CoP (cont.)
1.Sole Community Provider
Either 25 miles from nearest "participating primary care provider;" or
At least 15 miles and 30 minutes from nearest "participating primary care provider"
2.Major Community Provider
Medicare/Medicaid low income and uninsured patient utilization rate >= 51%; or lowincome patient utilization rate >= to 31%; and
Is accepting major share of Medicare/Medicaid low income and uninsured patients,regardless of ability to pay relative to other providers in the area
3.Specialty Clinic
OB/GYN or Peds
4.Extremely Rural Provider
Accepting Medicare/Medicaid low income and uninsured patients regardless of abilityto pay and located in a "frontier county" (<6 ppsm) or a RUCA Level 10
RHC must submit an exception request – not StatePCO, not automatic
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RHC Proposed Changes In CoP (cont.)
Staffing Issues
Current
RHCs required to employ all midlevels providingservices
Proposed
Non-physician practitioners may furnish servicesunder contract
At least one must be directly employed at all times
Signed contract with responsibilities/standards
1 year midlevel staffing waiver available
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RHC Proposed Changes In CoP (cont.)
Other Proposed Changes
QAPI program
Infection control program
Post hours of operation
Required common emergency equipment
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RHC Proposed Changes In CoP (cont.)
Payment Issues
Current
RHCs/FQHCs receive 80% of reasonable costsregardless of deductible and coinsurance amountsbilled to Medicare beneficiaries
Proposed
Payment equal to reasonable costs less coinsuranceand deductible amounts billed
In no case may total payment (including copays)exceed 80% of reasonable costs
![MCj04247840000[1]](data/images/img11.png)
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Current
Per visit payment limit exception currently available tohospital-based RHCs (fewer than 50 beds)
Proposed
New hospital-based exception to per visit limit if:
SCH or EACH located in a Level 9 or Level 10 RUCAand
Average daily patient census that does not exceed 40
RHC Proposed Changes In CoP (cont.)
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HPSA 101 for RHCs
Highlights from the complex world of federal shortagedesignation!
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Types of Federal ShortageDesignations
Health Professional Shortage Area (HPSA) –shortage of providers for population
115 primary care, 73 dental & 105 mental health
Medically Underserved Area/Population(MUA/MUP) – provider shortage plus otherpopulation need (infant, aging, low-income)
74 MUA/MUPs
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HPSA – General Criteria
Rational service area – county, subcounty, census tracts;contiguous; similar pop. characteristics
Contiguous areas – providers not readily available insurrounding areas
Population to primary care MD ratio
Must be re-designated every 4 years
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Designations for RHC Cert.
Geographic primary care HPSA – 3500:1 FTE or 3000:1FTE for high need (FPL or wait times)
Low-income pop. HPSA – 3000:1 FTE
MUA – index of FPL, Inf. Mort, > 65, pop to providerratio, harder for rural areas
Governor’s Shortage Designation
Essential community provider exception (proposed)
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Designations for RHCs - More
Each shortage designation type must be reviewed &updated every 4 years
Must reflect provider shortage
Must be federally approved
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Proposed Gov’s Shortage Designation
Rational area & rural
Pop. to provider ratio – 2400:1 or 2000:1 for high need
High need = above state average for FPL, > 65,unemployed, uninsured
Provide financial access (MA, MR SFS)
Contiguous area not evaluated
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Gov’s Designation – Next Steps
Testing completed – 9 of 11 at-risk RHCs will meetproposed criteria
Finish Wisconsin application for new Gov’s Designation,work with Dept. and Gov’s Office to submit to HRSA
Resolve any issues with HRSA
Once WI Process/criteria approved, state can requestthat specific area’s be designated by HRSA
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Designations & Benefits
National Health Service Corps – loan repayment **ARRA expansion
WI Loan Assistance Program
J-1 visa waiver program – foreign MDs (primary care orspecialists)
Medicare 10% HPSA incentive payment
Medicaid HPSA bonus for primary care
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HPSA Rule & Proposed Changes
Status
2/29/08 – Fed. Reg. MUP/HPSA Rule & revised criteria
6/2/08 – HRSA extended comment period
6/23/08 – HRSA withdrew the Rule, and is nowreviewing comments and developing revisions. NewRule to be published – date tbd.
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HPSA Options for new RHCs
Check primary care HPSA status
Request a new PC HPSA – provides access to more benefitsthan a Gov’s Designation
Submit request to WI PCO:
anne.dopp@dhs.wisconsin.gov
Request a Governor’s Designation
Questions?
T
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