[§346-53.64]  Federally qualifiedhealth center or rural health clinic visit.  (a)  Services eligible forprospective payment system reimbursement are thoseservices that are furnished by a federally qualified health center or ruralhealth clinic that are:

(1)  Within the legal authority of a federallyqualified health center to deliver, as defined in section 1905 of the SocialSecurity Act;

(2)  Actually provided by the federally qualifiedhealth center, either directly or under arrangements;

(3)  Covered benefits under the medicaid program, asdefined in section 4231 of the State Medicaid Manual and the Hawaii medicaidstate plan;

(4)  Provided to a recipient eligible for medicaidbenefits;

(5)  Delivered exclusively by health careprofessionals, including physicians, physician’s assistants, nursepractitioners, nurse midwives, clinical social workers, clinical psychologists,and other persons acting within the lawful scope of their license orcertificate to provide services;

(6)  Provided at the federally qualified healthcenter's practice site, a hospital emergency room, in an inpatient setting, atthe patient's place of residence, including long term care facilities, or atanother medical facility; and

(7)  Within the scope of services provided by the Stateunder its fee-for-service medicaid program and its health QUEST program, on andafter August 1994, and as amended from time to time.

(b)  Contacts with one or more healthprofessionals and multiple contacts with the same health professional that takeplace on the same day and at a single location constitute a single encounter,except when one of the following conditions exists:

(1)  After the first encounter, the patient suffersillness or injury requiring additional diagnosis or treatment; or

(2)  The patient makes one or more visits for otherservices such as dental or behavioral health.  Medicaid may pay for a maximumof one visit per day for each of these services in addition to one medicalvisit.

(c)  A federally qualified health center orrural health clinic that provides prenatal services, delivery services, andpost natal services may elect to bill the managed care organization for allsuch services on a global payment basis.  Alternatively, it may bill forprenatal and post natal services separately from delivery services and be paidthe per visit prospective payment system reimbursement for prenatal and postnatal visits.  In this case, it may bill the managed care organizationseparately for inpatient delivery services that are not eligible forprospective payment system reimbursement. [L Sp 2008, c 8, pt of §2]

 

Note

 

  Section effective upon approval of the Hawaii medicaid stateplan by the Centers for Medicare and Medicaid Services.  L Sp 2008, c 8, §9.

  L Sp 2008, c 8, §5 provides:

  "SECTION 5.  The department of health may provideresources to nonprofit, community-based health care providers for directmedical care for the uninsured, including:

(1) Primarymedical;

(2) Dental;

(3) Behavioralhealth care; and

(4) Ancillaryservices, including:

(A) Education;

(B) Follow-up;

(C) Outreach;and

(D) Pharmacyservices.

Distribution of funds may be on a "per-visit" basis,taking into consideration need on all islands."