Medi-Cal: federally qualified health clinics: rural health clinics.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that federally qualified health center (FQHC) services and rural health clinic (RHC) services, as defined, are covered benefits under the Medi-Cal program, to be reimbursed, in accordance with Medicare reasonable cost principles, and to the extent that federal financial participation is obtained, to providers on a per-visit basis that is unique to each facility. Existing law prescribes the reimbursement rate methodology for establishing and adjusting the per-visit rate. Under existing law, if an FQHC or RHC is partially reimbursed by a 3rd-party payer, such as a managed care entity, the department is required to reimburse the FQHC or RHC for the difference between its per-visit rate programs on a contract-by-contract basis. Existing law authorizes an FQHC or RHC to apply for an adjustment to its rate based on a change in the scope of service that it provides within 150 days following the beginning of the FQHC's or RHC's fiscal year. Existing law provides that the department's implementation of FQHC and RHC services is subject to federal approval and the availability of federal financial participation. This bill would require the methodology of the adjusted per-visit rate to exclude, among other things, a provider productivity standard. The bill would authorize an FQHC or RHC to apply for a rate adjustment for the adoption, implementation, or upgrade of a certified electronic health record system as a change in the scope of service. The bill would clarify specified terms, including the meaning of "scope of "service," would expand the meaning of "visit" to include FQHC and RHC services rendered outside of the facility location, and would modify how the department reimburses an FQHC or RHC that is partially reimbursed by a 3rd-party payer. The bill would require a health care provider who contracts with an FQHC or RHC to provide services outside of the facility on behalf of the facility, and for which the facility bills for those services, to comply with specified requirements, including actively serving patients in the same county as, or a county adjacent to, the physical location of the billing FQHC or RHC. The bill would repeal the provisions authorizing an FQHC or RHC to apply for an adjustment to its rate based on a change in the scope of service that it provides within 150 days following the beginning of the FQHC's or RHC's fiscal year, and would instead extend the time frame for an FQHC or RHC to file a scope of service rate change to any time during the fiscal year. The bill would require the department to ensure that department staff conducting audits related to FQHC and RHC services receive appropriate training on federal and state laws governing those facilities, and would make various conforming and technical changes.