Implementer § 241 — FQHC Payments
The bill sets several requirements related to DSS’s payments to federally qualified health centers (FQHCs) for services provided under medical assistance programs (e.g., Medicaid). These requirements include, among other things, limitations on payments for nonemergency dental visits at FQHCs.
Current law authorizes, but does not require, DSS to reimburse FQHCs for multiple services provided in a day, regardless of what type of services the center provides. Generally, the bill instead requires DSS to reimburse FQHCs (1) on an all-inclusive encounter rate per client encounter, based on a prospective payment system under federal law and state existing regulations, and (2) according to requirements in existing state regulations. For reimbursement purposes, the bill considers the following types of patient encounters single encounters: (1) an encounter with more than one health professional for the same type of service and (2) multiple interactions with the same health professional that occur on the same day, unless a patient suffers illness or injury after the first encounter and requires additional diagnosis and treatment.
The bill prohibits FQHCs from providing nonemergency, periodic dental services on different dates of service to enable billing for separate encounters. It requires FQHCs to complete these services in one visit (e.g., exams, prophylaxis, and radiographs such as bitewings, complete series, and periapical imaging). The bill makes second visits to complete any service normally included during a nonemergency periodic dental visit ineligible for reimbursement unless the visit is medically necessary and clearly documented that way in the patient’s dental record.
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