California § 14138.14 - A participating FQHC shall be compensated for the APM scope of services provided

§ 14138.14. A participating FQHC shall be compensated for the APM scope of services provided

(a) A participating FQHC shall be compensated for the APM scope of services provided to its APM enrollees pursuant to this section. (b) A participating FQHC shall receive from the principal health plan or applicable subcontracting payer reimbursement for each APM enrollee in the form of a clinic-specific PMPM. The department shall determine the clinic-specific PMPM taking into account all the following factors: (1) Historical utilization of applicable FQHC services in each APM aid category. (2) The participating FQHC’s prospective payment system rate and applicable adjustments relevant for the fiscal year, such as annual rate adjustments. (3) The projected mix of assigned members across the APM aid categories. (4) Other trend and utilization adjustments as appropriate in order to reflect the level of reimbursement that would have been received by the participating FQHCs in the absence of the APM project. (c) A participating FQHC and applicable principal health plan or subcontracting payer may enter into arrangements in which the clinic-specific PMPM amount required in subdivision (b) is paid in more than one capitated increment, as long as the total per-member capitation each month received by the participating FQHC is at least equal to the clinic-specific PMPM. (d) In cases where a subcontracting payer is involved, the principal health plan shall demonstrate and certify to the department that it has contracts or other arrangements in place that provide for meeting the requirements in subdivision (b) and to the extent that the subcontracting payer fails to comply with the applicable requirements in this article, the principal health plan shall then be responsible to ensure the participating FQHC receives all payments due under this article in a timely manner. (e) The department shall adjust the amounts in subdivision (b) as necessary to account for any change to the prospective payment system rate for participating FQHCs, including changes resulting from a change in the Medicare Economic Index pursuant to subdivision (d) of Section 14132.100, any changes in the FQHC’s scope of services pursuant to subdivision (e) of Section 14132.100, and changes in the projected mix of assigned members across APM aid categories. (f) An FQHC site participating in the APM project shall not receive traditional wrap-around payments for visits within the APM scope of services it provides to its APM enrollees for any service period in which it participates in the APM project. A participating FQHC site shall not be entitled to make a reconciliation request pursuant to Section 14132.100 or 14087.325 in connection with visits within the APM scope of services provided to APM enrollees for any service period in which it participates in the APM project. (g) A principal health plan or subcontracting payer shall not terminate a contract with a participating FQHC for the specific purpose of circumventing the payment obligations implemented pursuant to this section. (h) FQHCs shall have the right to pursue any available remedy against Medi-Cal managed care plans or subcontracting payers, including judicial review, as appropriate in connection with the requirements of this section.