§ 40-8-26. Community health centers. (a) For the purposes of this section the term community health centers refers to federally qualified health centers and rural health centers.

(b) To support the ability of community health centers to provide high quality medical care to patients, the executive office of health and human services ("executive office") shall adopt and implement a methodology for determining a Medicaid per-visit reimbursement for community health centers that is compliant with the prospective payment system provided for in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2001. The following principles are to ensure that the prospective payment rate determination methodology is part of the executive office overall value purchasing approach.

(c) The rate determination methodology will (i) fairly recognize the reasonable costs of providing services. Recognized reasonable costs will be those appropriate for the organization, management, and direct provision of services and (ii) provide assurances to the executive office that services are provided in an effective and efficient manner, consistent with industry standards. Except for demonstrated cause and at the discretion of the executive office, the maximum reimbursement rate for a service (e.g. medical, dental) provided by an individual community health center shall not exceed one hundred twenty-five percent (125%) of the median rate for all community health centers within Rhode Island.

(d) Community health centers will cooperate fully and timely with reporting requirements established by the executive office.

(e) Reimbursement rates established through this methodology shall be incorporated into the PPS reconciliation for services provided to Medicaid eligible persons who are enrolled in a health plan on the date of service. Monthly payments by the executive office related to PPS for persons enrolled in a health plan shall be made directly to the community health centers.

(f) Reimbursement rates established through this methodology shall be incorporated into the actuarially certified capitation rates paid to a health plan. The health plan shall be responsible for paying the full amount of the reimbursement rate to the community health center for each service eligible for reimbursement under the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2001. If the health plan has an alternative payment arrangement with the community health center the health plan may establish a PPS reconciliation process for eligible services and make monthly payments related to PPS for persons enrolled in the health plan on the date of service. The executive office will review, at least annually, the Medicaid reimbursement rates and reconciliation methodology used by the health plans for community health centers to ensure payments to each are made in compliance with the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2001.

History of Section. (P.L. 2006, ch. 246, art. 35, § 2; P.L. 2017, ch. 302, art. 9, § 2.)