Medicaid increases Community Health Center reimbursement rate

Pursuant to a request made by the American Samoa Medicaid State Agency to amend the Medicaid State Plan, the Center for Medicare and Medicaid Services (CMS) has approved an increase in the DOH Federally Qualified Health Center's (FQHC community health centers) reimbursement rate to $150 per patient encounter. The FQHC's starting reimbursement rate was $50 per patient encounter.

This was confirmed by the director of the American Samoa Medicaid Office, Tofoitaufa Sandra Kīng-Young last Friday.

According to Tofoitaufa, Medicaid worked for nearly three years to design a payment method to allow it to reimburse the FQHC's community health centers and make it a Medicaid provider.

“Medicaid faced significant challenges creating a payment method because of the absence of utilization and financial data,” Tofoitaufa told Samoa News.

 “After innovative problem solving and persuasive policy advocacy by the Medicaid office, CMS finally approved that payment method in February 2017, which allowed the FQHC to waive the facility fee for patients.”

She continued, “The intent is to do away with the financial barrier that prevents our people from seeking preventive care and chronic care management to help keep them healthy and control our limited financial resources.”

Tofoitaufa said, “Our people tend to wait until it’s too late or when illnesses are so far along that it ends up requiring more expensive medical care or worse — affects their quality of life. We need to encourage our people to go to the community health centers for preventive care. “

The local Medicaid director said even though American Samoa had an FQHC that was eligible to be a Medicaid provider, the American Samoa Medicaid State Plan did not have a payment method defined in it to reimburse the FQHC. The Medicaid State Plan only had provisions for a provider to enroll but not to be paid.

And without a defined payment method, “there was no way we could pay the FQHC. We had to be creative in advocating for the change and providing creative solutions in order to move forward with approval.”

According to Tofoitaufa, “CMS approved the first payment method, with our intent and commitment to collect one year's worth of data to determine whether we could then request an increase for the DOH FQHC.

“Now that we have the first year of data, we moved quickly to request the increase to further benefit our community health centers. This is the near maximum encounter rate similar to the Prospective Payment System (PPS) rate FQHC's are generally eligible for — but because we do not do individual enrollment for Medicaid and the FQHC do not yet file a Medicare Cost Report for financial analysis purpose, we cannot use the PPS rate.”

“It's complicated,” she said.

Given the current data, Tofoitaufa said the FQHC is estimated to receive an additional $1.2 million in this fiscal year in new funding from Medicaid. She said the DOH FQHC is able to draw these additional federal funds because they have a local budget that they can use as local match.

“We are fortunate that DOH has a local budget to use to draw the additional federal funds that is real new monies to infuse in our territory, Tofoitaufa said. “The more the DOH FQHC's hire more doctors and more nurses to serve more people, they will be able to receive more federal funds so long as they have the local match.”

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