7 AAC 43.870. Enrollment and reporting

(a) To be eligible to be a federally qualified health center under 7 AAC 43.870 - 7 AAC 43.874, a provider must meet at least one of the following eligibility requirements for the entire period for which Medicaid services are rendered:

(1) a provider is receiving a grant under at least one of the following:

(A) 42 U.S.C. 254b (Migrant Health Centers);

(B) 42 U.S.C. 254c (Community Health Centers);

(2) a provider is receiving money from a grant listed in (1) of this subsection under a contract with the grant recipient, and the provider also meets the requirements to receive that type of grant;

(3) a provider is determined by the United States Department of Health and Human Services, Center for Medicare and Medicaid Services (CMS), to meet the requirements for receiving one of the grants listed in (1) of this subsection;

(4) a provider is a health program or entity operated by the United States Indian Health Service or a hospital or clinic operated by a tribal organization, as defined in 25 U.S.C. 450b(1), under a funding agreement under 25 U.S.C. 450-458aaa (Indian Self-Determination and Education Assistance Act) as amended by P.L. 106-260 (Tribal Self-Governance Amendments of 2000).

(b) To enroll with the division, a federally qualified health center

(1) must be enrolled as a Medicare provider;

(2) must participate as a federally qualified health center in accordance with this section and 7 AAC 43.872, 42 C.F.R. 405.2430 - 405.2452, and 42 C.F.R. 491.1 - 491.11;

(3) must provide the department with a letter from United States Department of Health and Human Services, Center for Medicare and Medicaid Services (CMS), certifying the entity as a federally qualified health center provider, and must provide a copy of its grant notice; however, an entity operated by the United States Indian Health Service or a hospital or clinic operated by a tribal organization, as defined in 25 U.S.C. 450b(1), under a funding agreement under 25 U.S.C. 450-458aaa (Indian Self-Determination and Education Assistance Act) as amended by P.L. 106-260 (Tribal Self-Governance Amendments of 2000) is exempt from providing documentation of certification;

(4) except as provided in (5) of this section, may not be enrolled as another type of Medicaid provider for primary care or ambulatory services provided by the federally qualified health center; and

(5) must meet the enrollment requirements for each service that the federally qualified health center provides by provider type as required under this chapter, and must enroll separately under this chapter as a dental provider or a dispensing pharmacy provider, if the entity provides dental or dispensing pharmacy services.

(c) If a federally qualified health center operates in more than one site in the state, each site must enroll separately and independently meet the requirements of this section.

(d) For each site where it operates, a federally qualified health center shall maintain sufficient financial records and statistical data to allow the department to identify and verify the costs and charges associated with providing services at each site.

(e) On or before the last day of the fifth month after the close of its fiscal year, a federally qualified health center shall file an annual year-end report, even if the center did not provide medical services to Medicaid-eligible recipients during that fiscal year. The annual year-end report must contain the items listed in the definition of "year-end report" in 7 AAC 43.709 except that

(1) Medicare home office cost statements are not required;

(2) the required reconciliation of the post-audit working trial balance must be to the Medicare cost report worksheets A, A-1, and A-2; and

(3) the report must also include a worksheet detailing the total number of federally qualified health center visits for the center's fiscal year; the worksheet must include federally qualified health center visits for dental and other ambulatory services.

(f) If no change in the scope of services occurred during the federally qualified health center's fiscal year, and the federally qualified health center does not intend to request a change, the federally qualified health center shall submit to the department, on or before the last day of the fifth month after the close of that fiscal year, a written statement indicating that no change in the scope of services occurred or is being requested.

(g) If a change in scope of services occurred during the federally qualified health center's fiscal year, the federally qualified health center shall submit to the department the additional reports listed in this subsection. The data contained in these reports will be used to evaluate the change in scope of service request made under 7 AAC 43.872 and 7 AAC 43.860(j) , to adjust the federally qualified health center payment rates in accordance with those provisions, and to ensure, in accordance with 7 AAC 43.872 and 7 AAC 73.860(g)(4), that the prospective payment rate does not exceed upper payment limits. The reports must be submitted on or before the last day of the fifth month after the close of the federally qualified health center fiscal year during which the change in the scope of services occurred, and on or before the last day of the fifth month after 12 continuous months of operation with the change. The reports must include the following:

(1) a worksheet detailing the total number by which federally qualified health center visits increased or decreased for the center's fiscal year due to the change in the scope of services;

(2) a narrative report that

(A) identifies the date the change in the scope of services occurred; and

(B) provides a description of the type of change in the scope of services;

(3) a spreadsheet that details the costs that are associated with the change in the scope of services and reported on the Medicare cost report; the spreadsheet must

(A) identify the working trial balance, account numbers, and cost centers; and

(B) list all expense amounts associated with the change in the scope of services.

(h) If the facility receives an extension for filing the Medicare cost report from the Medicare intermediary, the facility must forward a copy of the intermediary's letter that grants the extension to the facility to the department. The department will then grant an extension for the year-end report and the change-in-scope report to coincide with the due date given by the Medicare intermediary. Otherwise, for good cause shown to the department's satisfaction, the department will grant a 30-day extension of the due date for submitting the information required under (f) - (g) of this section. In order to receive an extension from the department, a federally qualified health center must submit to the department an extension request in writing before the due date. For purposes of this subsection, "good cause"

(1) means circumstances beyond the control of the federally qualified health center that cause the reporting due date to be missed by several days; and

(2) includes natural disasters, hazardous weather, illness of the individual making the request, or specific medical emergencies that preclude timely submission.

(i) The department will withhold 20 percent of the payment due a federally qualified health center if the center fails to submit complete information as required in (e) - (g) of this section. The department will restore, without interest, a payment withheld under this subsection, if the federally qualified health center submits complete information as required in (e) - (g) of this section.

(j) The department may conduct audits, perform special analysis, review the records of a federally qualified health center to verify compliance with Medicare and Medicaid laws, audit claims for reimbursement submitted or paid, and make adjustments based on audits to a federally qualified health center's payment rate. A federally qualified health center shall provide to the department financial and all other information regarding Medicaid claims for services provided to eligible recipients, shall provide Medicare cost reports upon request, and shall provide access to all facilities and records.

(k) A federally qualified health center may terminate its agreement to participate in the federally qualified health center program by submitting a written notice to the department and identifying a termination date not less than 30 days after submitting the notice of termination.

History: Eff. 9/28/95, Register 135; am 7/11/2002, Register 163; am 3/18/2006, Register 177

Authority: AS 47.05.010

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