1. 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, Current Requirements, and New Developments August 19, 2009

2. Agenda 1. Current RHC conditions of participation 2. Current RHC benefits 3. CMS Proposed Rule for RHCs (including shortage designation requirement) 4. HPSA 101 for RHCs: HPSA types & requirements for RHCs HPSA linked benefits Governor’s Shortage Designation status

3. 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. 4 Current RHC CoPs Physical Plant Preventive maintenance program (general equip., patient care equip., drug/biological stored appropriately, housekeeping) Emergency Procs. (staff training, exit signs, etc.)

5. 5 Current RHC CoPs Organizational Structure Medical Director Policies and lines of authority in writing

6. 6 Current RHC CoPs Staffing One or more physicians – at least once every 2 weeks Medical direction Available for emergencies One or more midlevels (NP, PA, CNM, CSW, Clinical Psychologist) At least 50% of RHC working hours

7. 7 Current RHC CoPs Staffing (cont.) Physician and midlevel joint duties Develop, execute and periodically review written policies and services

8. 8 Current RHC CoPs RHC Services Outpatient primary services – conditions which cause a patient to present at a physician's office Services commonly furnished in physician office or at system entry point Consistent with written policies Developed by "group of professional personnel" that includes 1+ physicians and 1+ midlevels. At least 1 member NOT member of RHC staff Reviewed at least annually Patient care, records, drug storage, etc.

9. 9 Current RHC CoPs RHC Direct Services Furnished by clinic or center staff Lab: Urinalysis, hemoglobin, glucose, occult blood, pregnancy, primary culturing, Emergency: Common first response procedures and drugs (antibiotics, anticonvulsants, local anesthetics, etc.)

10. 10 Current RHC CoPs Arrangements Must have arrangement or agreement with Medicare or Medicaid provider to furnish Inpatient care Physician services Specialized diagnostics (imaging and lab) Records Must maintain records system consistent with policies managed by designated staff person, among other requirements.

11. 11 Current RHC CoPs Program Evaluation Must conduct comprehensive annual program evaluation

12. 12 Payment for RHC Services All-inclusive rate for each visit Subject to per-visit limit Based on FI/MAC calculated cost per visit

13. 13 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)

14. 14 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

15. 15 RHC Proposed Changes - CoPs and Payment Provisions

16. 16 RHC Proposed CoP Changes Status February 28, 2000 – Proposed Rule December 24, 2003 – Final Rule September 22, 2006 – Suspended effectiveness of Final Rule > 3 years before 2003 Rule was finalized June 28, 2008 Proposed Rule – "Re-implementing" December 2003 Final Rule

17. 17 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?)

18. 18 RHC Proposed Changes In CoP (cont.) What if the HPSA isn't updated? Proposed Grandfather rule terminated – decertification possible Termination automatically effective 180 days after failure to comply with location requirements Would be able to avoid immediate decertification by Submitting application to update shortage area; or Submitting essential provider application

19. 19 RHC Proposed Changes In CoP (cont.) Impact of Provider-Based RHC Decertification on CAH Status Grandfathered provider-based clinic (1/1/08) – can be within 35 miles of another hospital CAHs can convert existing clinic (provider-based or not) to a provider-based RHC, CAH status not compromised Will decertification of that RHC jeopardize CAH?

20. 20 RHC Proposed Changes In CoP (cont.) Proposed If in UA or non-shortage area, can apply 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 are adjacent thereto)

21. 21 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 low income 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 ability to pay and located in a "frontier county" (<6 ppsm) or a RUCA Level 10 RHC must submit an exception request – not State PCO, not automatic

22. 22 RHC Proposed Changes In CoP (cont.) Staffing Issues Current RHCs required to employ all midlevels providing services Proposed Non-physician practitioners may furnish services under contract At least one must be directly employed at all times Signed contract with responsibilities/standards 1 year midlevel staffing waiver available

23. 23 RHC Proposed Changes In CoP (cont.) Other Proposed Changes QAPI program Infection control program Post hours of operation Required common emergency equipment

24. 24 RHC Proposed Changes In CoP (cont.) Payment Issues Current RHCs/FQHCs receive 80% of reasonable costs regardless of deductible and coinsurance amounts billed to Medicare beneficiaries Proposed Payment equal to reasonable costs less coinsurance and deductible amounts billed In no case may total payment (including copays) exceed 80% of reasonable costs

25. 25 Current Per visit payment limit exception currently available to hospital-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 RUCA and Average daily patient census that does not exceed 40 RHC Proposed Changes In CoP (cont.)

26. 26 HPSA 101 for RHCs Highlights from the complex world of federal shortage designation!

27. 27 Types of Federal Shortage Designations 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 other population need (infant, aging, low-income) 74 MUA/MUPs

28. 28 HPSA – General Criteria Rational service area – county, subcounty, census tracts; contiguous; similar pop. characteristics Contiguous areas – providers not readily available in surrounding areas Population to primary care MD ratio Must be re-designated every 4 years

29. 29 Designations for RHC Cert. Geographic primary care HPSA – 3500:1 FTE or 3000:1 FTE for high need (FPL or wait times) Low-income pop. HPSA – 3000:1 FTE MUA – index of FPL, Inf. Mort, > 65, pop to provider ratio, harder for rural areas Governor’s Shortage Designation Essential community provider exception (proposed)

30. 30 Designations for RHCs - More Each shortage designation type must be reviewed & updated every 4 years Must reflect provider shortage Must be federally approved

31. 31 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

32. 32 Gov’s Designation – Next Steps Testing completed – 9 of 11 at-risk RHCs will meet proposed 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 request that specific area’s be designated by HRSA

33. 33 Designations & Benefits National Health Service Corps – loan repayment ** ARRA expansion WI Loan Assistance Program J-1 visa waiver program – foreign MDs (primary care or specialists) Medicare 10% HPSA incentive payment Medicaid HPSA bonus for primary care

34. 34 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 now reviewing comments and developing revisions. New Rule to be published – date tbd.

35. 35 HPSA Options for new RHCs Check primary care HPSA status Request a new PC HPSA – provides access to more benefits than a Gov’s Designation Submit request to WI PCO: anne.dopp@dhs.wisconsin.gov Request a Governor’s Designation

36. Questions?

37. Thank you! 747078