FQHC and rural health clinics


CA | DE | DC | FL | HI | IN | KY | ME | MI | MN | MO | MT | NE | NEBH | NV
NJ | NM | NY |ND | OH | OR | PABH | RI | UT | VA | WV

CA

"6.6.19   FQHC Services
Contractor shall meet federal requirements for access and reimbursement for FQHC services, including those in 42 United States Code Section 1396 b(m) and Medicaid Regional Memorandum 93-13.  If FQHC services are not available in the provider network of either Medi-Cal managed care contractor in the county, Contractor shall reimburse FQHCs for services provided out-of-plan to Contractor's Members at the interim FQHC rate determined by DHS.  If FQHC services are not available in Contractor's provider network, but are available within DHS' time and distance standards for access to Primary Care for Contractor's Members in the other Medi-Cal managed care contractor's provider network in the county, Contractor shall not be obligated to reimburse FQHCs for services provided out-of-plan to Members (unless authorized by Contractor).

For family planning and Emergency Services, the provisions of Sections 6.6.16 and 6.7.4.5 through 6.7.4.9 apply."  California  Contract, page 109.

DE

"6.4  Basic Benefit Package
The DHSSHP will provide standard benefits similar to the acute care benefits that are currently provided under Delaware's Medicaid program…"   Delaware RFP, page II.37

"Appendix H
Overview Medicaid Covered Services

SERVICE TYPE/BASIC BENEFIT PACKAGE...
Other...
FQHC/Rural Health Clinics/Covered…"  Delaware RFP, Appendix H, page 1.

DC

"H.  COVERAGE AND BENEFITS
  1.  Covered services
  a.  This contract provide for coverage and provision by Provider of all medical assistance benefits and  services that are listed in Attachment I, which is incorporated herein as part of this contract…"  District of Columbia Contract, page 21.

"Attachment I
Covered Services

A.  General Classes of Covered Benefits
Coverage of all benefits by Provider shall conform to the definition of the benefit set forth in federal statue and regulation.  The following general categories of benefits are included in the state plan and are not otherwise exempt under this contract...

  3.  Federally qualified health center services and other ambulatory services covered by federally qualified health centers."  District of Columbia Contract, page 21 and Attachment I, page 1.

FL

"4. Physician Services.  Physician services are those services and procedures rendered by a licensed physician at a physician's office, patient's home, hospital, nursing facility or elsewhere when dictated by the need for preventive, diagnostic, therapeutic or palliative care, or for the treatment of a particular injury, illness or disease...For purposes of this contract... rural health clinic services… [and ] federally qualified health center (FQHC) services,  are included as physician services... and, as such, are included in the capitation rate paid to the plan..."  Florida Contract, page 77.

HI

"Clinic Services
A.  For adults
  1. Rural Health Clinic services are covered
  2. Federally qualified health center (FQHC) services are covered
  3. Other clinic services are covered if these services are allowed under federal Medicaid rules and regulations...

B.  For children
  1. Clinic coverage for adults apply"  Hawaii RFP, Appendix H, page 4.

IN

"3.1.3  Medicaid Covered Services
The Indiana Medicaid program covers the following services for all eligible recipients.  The specific services covered under the managed care initiative are specified in Section 4.4 of this RFP...
  *  Rural health clinic and FQHC services…"  Indiana RFP, page 3-3 - 3-4.

"4.4  Description Of Managed Care Services
4.4.1  Hoosier Healthwise RBMC Covered Services...
The following is a general list of covered services under the RBMC program, listed by general categories; an abbreviated list of covered services within each category also is provided...

4.4.2  Special Provisions
Specific coverage and payment policies apply to certain types of services and providers, including the following:
  *  Federally Qualified Health Centers (FQHCs)
  *  Rural Health Clinics (RHCs)..."  Indiana RFP, pages 4-4 -  4-6.

"CHIP Benefit Package

Service:  Rural Health Clinics

Indiana Medicaid Benefits:  Reimbursement available for services provided by a physician, nurse practitioner, or appropriately licensed, certified, or registered therapist employed by the rural health clinic.

CHIP Benefit Package: Reimbursement available for services provided by a physician, nurse practitioner, or appropriately licensed, certified, or registered therapist employed by the rural health clinic.

Service:  Federally Qualified Health Centers (FQHCs)

Indiana Medicaid Benefits:  Reimbursement available for medically necessary services provided by licensed health care practitioners.

CHIP Benefit Package:  Reimbursement available for medically necessary services provided by licensed health care practitioners."  Indiana SCHIP Amendment, Attachment C-1, page 1.

KY

"D.  Services to Be Provided
  1.  Covered Services
  The Contractor shall provide Covered Services in accordance with Section 7.9.1 and Attachment VIII of the RFA."  Kentucky Contract, page 21.

"Covered Services...
Medical Services, including those provided by...FQHCs, Primary Care Centers and Rural Health Clinics...Preventive Health Services, including those currently provided in Public Health Departments, FQHCs/Primary Care Centers, and Rural Health Clinics."  Kentucky RFA, Attachment VIII, page 57.

ME

"B.  COVERED SERVICES...
Covered Services: ...
• Rural Health Clinics
• Federally Qualified Health Centers..."  Maine Contract, pages 20-21.

MI

"II-I SPECIAL COVERAGE PROVISIONS...
5. Federally Qualified Health Centers (FQHCs)
The Contractor agrees to provide Enrollees with access to services provided through a Federally Qualified Health Center (FQHC) if the Enrollee resides in the FQHC's services area and if the Enrollee requests such services…  If a Contractor has an FQHC in its provider network and allows members to receive medically necessary services from the FQHC, the Contractor has fulfilled its responsibility to provide FQHC services and does not need to allow its members to access FQHC services out-of-network...

FQHC services must be prior authorized by the Contractor, however the Contractor may not refuse to authorize medically necessary services if the Contractor does not have a FQHC in the network for the services area (county)..."  Michigan Contract, pages 22, 25-26.

MN

"Section 6.2. GAMC Covered Services. The HEALTH PLAN shall provide, or arrange to have provided to Enrollees comprehensive preventive, diagnostic, therapeutic and rehabilitative health care services as defined in Minnesota Statutes, Section 256D.03. Except for Section 6.2.16, these services shall be provided to the extent that this law was in effect on the effective day of this contract. These services shall include, but are not limited to, the following…

Section 6.2.15. Physician, Clinic and Community Health Clinic Services."  Minnesota Contract, pages 59-60.

"Section 9.2.8.  Community Clinic, Community Mental Health Centers, and Community Health Services Agencies Subcontracting Requirements.  The HEALTH PLAN shall contract with nonprofit community clinics, community mental health centers, or community health services agencies to provide services to Enrollees who choose to receive services from the clinic or agency, if the clinic or agency agrees to payment rates that are competitive with rates paid toe other HEALTH PLAN providers for the same or similar services, pursuant to Minnesota Statutes, Section 256B.69, Subdivision 22.  The HEALTH PLAN may reasonably require a community clinic, community mental health center, or community health services agency to comply with the same or similar contract terms that the HEALTH PLAN requires of the HEALTH PLAN's other Participating Providers, except that the HEALTH PLAN cannot exclude coverage for a covered service provided by a clinic or agency in a subcontract with a clinic or agency.  The STATE will provide the HEALTH PLAN with a list of all nonprofit community clinics, community mental health centers, and community health services agencies within the Service Area within one week of the effective date of the Contract unless the STATE has already provided an updated list as part of the most recent PMAP RFO process or as part of the RFP for this contract.  The HEALTH PLAN must submit a written invitation to contract to each nonprofit community health clinic, community mental health center or community health services agency within the Service area within 30 days of the effective date of this Contract.  Within 90 days of the effective date of this Contract, the HEALTH PLAN shall submit to the STATE one of the following for each nonprofit community clinic, community mental health center or community health services agency within the HEALTH PLAN's Service Area:  9a)  the signature page from an executed contract, or (b) a letter from the nonprofit community clinic, community mental health center or  community health services agency stating that they are declining the HEALTH PLAN's contract offer, (b) a letter from the nonprofit community clinic, community mental health center or community health services agency stating that they are declining the HEALTH PLAN's contract offer, or (c) a progress report on the status of negotiations with the community clinic, community mental health center or community health services agency.  This progress report shall be updated in writing on a quarterly basis, until (a) or (b) are achieved."  Minnesota Contract, pages 84-85.

MO

"Federally Qualified Health Centers and Rural Health Clinics:  The health plan must include Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) in its network unless it can demonstrate that it has both adequate capacity and an appropriate range of services to provide care for the expected enrollment in a service area without contracting with Federally Qualified Health Centers or Rural Health Clinics (a description of Federally Qualified Health Center/Rural Health Clinic)…"  Missouri RFP, page 27.

"FEDERALLY  QUALIFIED HEALTH CENTER BENEFITS (FQHC)
Federally Qualified Health Center (FQHC) services are the responsibility of the health plans.  FQHC 'Core' services that must be performed in an FQHC setting are listed in Attachment Two.  To receive FQHC provider status, a health center must be certified by the Public Health Service, be certified for participation in Medicaid and enrolled with Missouri as a FQHC…"  Missouri RFP, Attachment Five.

"RURAL HEALTH CLINICS (RHC)
Rural Health Clinics (RHC) are clinics located in a rural area designated as a shortage area for primary care.  RHC services that must be performed in an RHC setting are listed in Attachment Two…"  Missouri RFP, Attachment Five.

"Federally Qualified Health Centers/Rural Health Clinics
Category of Service

Covered Service:
Core services as defined in Section 1861 (aa) (a) (A)-(C) of the Social Security Act...

Category of Service:
Additional Federally Qualified Health Center Services
Covered Services:
In addition to the above Core Services, Federally Qualified Health Centers (as opposed to Rural Health Clinics) are required to provide preventive primary health services under sections 329, 330 and 340 of the Public Health Service Act and defined in Regulation 405.2448.

Category of Service:
Other Ambulatory Services
Covered Services:
Any other Title XIX-payable ambulatory services offered by the Medicaid program that the Federally Qualified Health Center undertakes to provide…"  Missouri RFP, Attachment Two.

MT

"2.5  PROVISION OF SERVICES
2.5.1  COVERED SERVICES...

HMO COVERED SERVICE/DESCRIPTION…
Services Included in Definition of  Federally Qualified Health Center (FQHC) Core Services (all persons)/ 'core services' as defined pursuant to Section 1861(aa)(1)(A-c) of the Social Security Act [42 U.S.C. Section 1395x aa)(1)(A-c)] including physician, nurse practitioner, physician assistant, nurse mid-wife, other specialized nurse practitioner, clinical psychologist and clinical social worker services except for mental health conditions as specified in Section 2.3(2) of Attachment 1 of the HMO contract, services and supplies incident to services of these PROVIDER, visiting  nurse services as specified in 42 CFR 405.2416 and preventive  primary services as specified in 42 CFR 440.220(b)(4) and any  other ambulatory services covered under Montana's MEDICAID plan; ARM 46.12.1701 & 1703...

Services Included in Definition of Rural Health Clinic (RHC) Core Services (all persons) /  'core services' as defined pursuant to Section 1861(aa)(1)(A-Definition of c) of the Social Security Act [42 U.S.C. Section 1395x aa)(1)(A-c)] including physician, nurse practitioner, physician Health assistant, nurse mid-wife, other specialized nurse practitioner, clinical psychologist and clinical social worker services except for mental health conditions as specified in Section 2.3(2) of Attachment 1 of the HMO contract, services and supplies incident to services of these PROVIDER, visiting nurse services as specified in 42 CFR 405.2416 and preventive primary services as specified in 42 CFR 440.22(b)(4) and any other ambulatory services covered under Montana's MEDICAID plan; ARM 46.12.1601 & 1603 & 1605…"  Montana Contract, pages 41-42.

NE

"4.1 Applicable Definitions: The following definitions apply under this contract: ...
4.1.3 The term 'Basic Benefits Package,' means the following medical/surgical services, representing a minimum benefits package, as defined in this contract and 471 Nebraska Administrative Code (NAC), that shall be provided by the plan to clients enrolled in the NHC: ...
(s) Federally Quality Health Center (FQHC), Rural Health or Tribal Clinic services (See 471 NAC 11-000, 29-000, 34-000 and Section 13.50 of this contract)…"  Nebraska Contract, page 7.

"13.45 Services in the Basic Benefits Package: Pursuant to this contract, services included in the Basic Benefits Package are...
(s) Federally Quality Health Center (FQHC), Rural Health or Tribal Clinic services (See 471 NAC 11-000, 29-000, 34-000 and Section 13.50 of this contract)…"  Nebraska Contract, pages 94-95.

"13.50 Federally Qualified Health Centers (FQHC): Each plan shall contract with any FQHC located within the designated coverage area or otherwise arrange for the provision of FQHC services."  Nebraska Contract, page 99.

NEBH

"11.56  Federally Qualified Health Centers (FQHC): If MH/SA services are provided by the FQHC, the PHP shall contract with an FQHC or otherwise arrange for the provision of FQHC services…"  Nebraska Behavioral Health Contract, page 69.

NV

"CONTRACTOR DUTIES AND RESPONSIBILITIES
I.  Medical Services
A.  Contractor Mandatory Managed Care Benefit Package.  Except as otherwise provided for in this contract, each Contractor must provide a comprehensive managed care benefit package to Medicaid participants…

B.  Contractor Covered Services.  At a minimum, the Contractor must provide directly or by subcontract all medical services listed below: ...
  31.  Rural Health Clinics and Federally Qualified Health Centers…"  Nevada Contract, page 21.

NJ

"ARTICLE 10
COVERED HEALTH CARE SERVICES
10.1 For enrollees who are Medicaid-eligible through Title XIX or the NJ KidCare Plan A program, the contractor shall provide or shall arrange to have provided comprehensive, preventive, diagnostic, rehabilitative, and therapeutic health care services to enrollees that include all services that Medicaid recipients are entitled to receive pursuant to Medicaid, subject to any limitations and/or excluded services as specified in Appendix A of this contract. DMAHS shall assure the continued availability and accessibility of Medicaid covered services not covered under this contract. All services provided shall be in accordance with the New Jersey State Plan for Medical Assistance, the New Jersey Medicaid Managed Care Plan, and all applicable statutes, rules, and regulations.

10.1.1  For beneficiaries eligible solely through NJ KidCare Plan B and Plan C, the contractor shall provide the same managed care services and products provided to enrollees who are eligible through Title XIX. However, non-HMO covered services (i.e., services that continue to be provided fee-for-service) will be limited to certain services for the NJ KidCare Plan B and C populations as indicated in Appendix A.

10.1.2  For beneficiaries eligible solely through NJ KidCare Plan D, the contractor shall provide the managed care services and products as delineated in Appendix S. Non-HMO covered services (i.e., services that will be provided fee-for-service by the Division of Medical Assistance and Health Services) will be limited to the services delineated in Appendix S.

10.2 The contractor hereby agrees that no distinctions shall be made with regard to the provision of services to Medicaid enrollees and the provision of services provided to the contractor's other non-Medicaid members unless required by this contract.

10.3  The scope of services to which an enrollee is entitled from the contractor, while deemed eligible for enrollment in the contractor's plan, is those services included in the benefits package. The remaining services to which enrollees are entitled under the Medicaid program but are not included in the contractor's benefits package will continue to be covered by Medicaid under its fee-for-service program."  New Jersey Contract, page 51.

"1.95  'Referral Services'...
  Exception B:  An enrollee may access services at a Federal Qualified Health Center (FQHC) in a specific enrollment area without the need for a referral when neither the contractor nor any other HMO has a contract with the Federally Qualified Health Center in that enrollment area and the cost of such services will be paid by the Medicaid fee-for-service program."  New Jersey Contract, page 20.

“APPENDIX S
NJ KIDCARE - PLAN D
BENEFITS PACKAGE-INCLUSIONS AND EXCLUSIONS
   The health care services listed below shall be provided by the contractor to enrollees as covered benefits rendered under the terms of this contract…

SERVICES INCLUDED IN THE CONTRACTOR'S BENEFITS PACKAGE
The following services must be provided and case managed by the contractor:
1.  Primary Care...
  -  Federally Qualified Health Center primary care services…"  New Jersey Contract, Appendix S, page 233.

NM

"2.D.6 Physical Health Services
The benefit package includes primary (including those provided in school-based settings) and specialty physical health services provided by a licensed practitioner performed within the scope of practice as defined by State law and set forth in Medical Assistance division Program manual Section MAD-711, MEDICAL SERVICES PROVIDERS; SECTION MAD-718.1, MIDWIFE SERVICES; Section MAD-718.2, PODIATRY SERVICES;  Section MAD-712 RURAL HEALTH CLINIC SERVICES; and Section MAD-713, FEDERALLY QUALIFIED HEALTH CENTER SERVICES."  New Mexico Contract, page 37.

NY

"I.  PREPAID BENEFIT PACKAGE DEFINITIONS OF COVERED SERVICES...
C. Other Covered Services
1.  Federally Qualified Health Center (FQHC) Services
FQHC services include physician services, services and supplies covered under SSA 1861 (s) (2) (A).  Services include primary health, referral for supplemental health services, health education, patient case management, including outreach, counseling, referral and follow-up services (see 42 USC 254c(a) & (b))."  New York Contract, Appendix K, pages K-13-K-22.

ND

"ATTACHMENT L:  COVERED SERVICES...
5.  Federally Qualified Health Centers - includes those core services defined in Section 1861 (aa) (1) (A-C) of the Social Security Act {42 U.S.C. Section 1395x (aa) (1) (A) - (C)}, services specified in 42 CFR 405.2416 and 405.2448 and any other ambulatory service covered under the Medicaid State Plan...
22. Rural health clinics - includes core services as defined in 42 CFR 440.20 (b) and any other ambulatory service that are otherwise covered in the Medicaid State Plan and provided directly by the rural health clinic."  North Dakota Contract, Attachment L, pages 1, 3.

OH

"E.  Service Delivery Specifications...
Federally Qualified Health Center (FQHC) Services - MCPs must meet specific requirements related to MCP contracts with federally qualified health centers (FQHCs)…
In order to receive a provider agreement, the applicant will be required during the proposal documentation phase to either (1) contract with an FQHC in each county included in the service area or (2) demonstrate that it will provide a comparable range of services without contracting with an FQHC."  Ohio RFP, page 28.

"APPENDIX A
BASIC BENEFIT PACKAGE BY SERVICE TYPE
The following types of services must be provided to covered persons by participating health plans and at least to the extent such services are covered by Ohio Medicaid.  Additional covered services required under this contract are outlined in the RFP...
11.  Clinic services (including funded rural health initiative programs [329 and 330], federally qualified health centers, and other providers approved by ODHS for cost-based reimbursement…"  Ohio RFP, Appendix A, page 1.

"5101:3-26-01  Managed care plan:  Definitions.
As used in Chapter 5101:3-26 of the Administrative Code: …
(DD)  'FQHC (federally qualified health center)' means a health services entity determined by the U.S. secretary of health and human services to be an FQHC or having received a grant under section 329, 330, or 340 of the Public Health Service Act as an FQHC and having contracted with ODHS to provide medicaid-covered services."  Ohio RFP, Appendix E, OAC 5101:3-26-01, page 3.

OR

"G.  Preventive Car Services...
For Preventive Care Services provided through any subcontractors (including, but  not limited to Federally Qualified Health Centers, Rural Health Clinics and County Health Departments), Contractor shall ensure that all services provided to OMAP Members are reported to Contractor and are subject to Contractor's Medical Case Management and record keeping responsibilities."  Oregon Contract, page 9.

PABH

"j.  The MCO must assure that members are provided reasonable access to behavioral health services provided by Federally Qualified Health Clinics (FQHC), wherever FQHCs services are available, within travel of 30 minutes (urban) and 60 minutes (rural)."  Pennsylvania Behavioral Health RFP, page 64.

RI

"2.08.07  FQHCs/RHCs
Contractor shall include FQHCs and RHCs in its network unless it can demonstrate that it has both adequate capacity and an appropriate range of services for vulnerable populations to serve the expected enrollment in a service area without contracting with FQHCs or RHCs (a description of FQHC services is included in Attachment G)."  Rhode Island RFP, page 37.

"FQHC AND RHC SERVICES
Core Services as Defined in Section 1861 (Aa)(1)(A)-(C) of the Social Security Act
Physician services
Services and supplies incidental to physician services (including drugs and biologicals that cannot be self-administered)
Pneumococcal vaccine and its administration and influenza vaccine and its administration
Physician assistant services
Nurse practitioner services
Clinical psychologist services
Clinical social work services
Services and supplies incidental to clinical psychologist and clinical social worker services as would otherwise be covered if furnished by or incidental to physician services
Part-time or intermittent nursing care and related medical supplies to a homebound individual (in the case of those FQHCs that are located in an area that has a shortage of home health agencies).

Additional FQHC Services
In addition to the above Core Services, FQHCs (as opposed to RHCs) are required to provide preventive primary health services under Sections 329, 330, and 340 of the Public health Service Act and defined in Regulation 405.2448.

Other Ambulatory Services
Any other Title XIX-payable ambulatory services offered by the Medicaid program that the FQHC undertakes to provide."  Rhode Island RFP, Attachment G, pages 1-2.

UT

"5.  Maternity Stays...
  c.  Post-Delivery Care
  Post-delivery care will be provided to a mother and her newborn child... in a federally qualified health center, a federally qualified rural health clinic..."  Utah Contract, Attachment B, pages 19-20.

VA

"3.  Clinic Services
The Contractor shall  cover clinic services which are defined as preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are provided to outpatients and are provided by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients, as set forth in 12 VAC 30-50-180.  With the exception of nurse-midwife services, clinic services are furnished under the direction of a physician or a dentist.  Renal dialysis clinic visits are also covered."  Virginia Contract, page 37.

WV

"Exhibit A...
HMO Covered Services...
The HMO must promptly provide or arrange to make available for enrollees all medically necessary services listed below and assume financial responsibility for the provision of these services...

MEDICAL SERVICE…/SCOPE OF BENEFITS/LIMITATION ON SERVICES
Rural Health Clinic Services: Including Federally Qualified Health Centers/Physician assistant, nurse practitioner, nurse midwife services, supplies, and intermittent visiting nurse care in designated shortage areas. Covered vaccines for adults and children must include Hepatitis B, Hepatitis A, Measles, Polio, Typhoid, Tetanus, and MMR/Drugs and biologicals are excluded…"
West Virginia Contract, Exhibit A, pages 1-2.

"MCP Covered Services
The following charts present as explanation of the medical services which the MCP is required to provide...
The MCP must promptly provide or arrange to make available for enrollees all medically necessary services listed below and assume financial responsibility for the provision of these services...

MEDICAL SERVICES/ SCOPE OF BENEFITS/ LIMITATION ON SERVICES
Rural Health Clinic Services: Including Federally Qualified Health Centers/ Physician assistant, nurse practitioner, nurse midwife services, supplies, and intermittent visiting nurse care in designated shortage areas./ Drugs and biological are excluded."  West Virginia RFA, Appendix A, pages A1, A5.