New Opportunities For FQHCs, Rural Health Clinics

Medicare rules include potential for new services, payments

The Centers for Medicare & Medicaid Services (CMS) released several proposed Medicare payment rules that include policies of potential interest for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).

The proposed 2024 hospital outpatient rule includes polices surrounding intensive outpatient programs (behavioral health). [Read CLA’s full regulatory summary on the hospital rule.] The proposed 2024 physician fee schedule includes policies on telehealth, digital health, and care integration services. [Watch for CLA’s full regulatory summary on the physician rule.]

Behavioral Health: Intensive Outpatient Programs

The 2024 proposed hospital outpatient prospective payment system rule includes a new Medicare benefit, as required under the Consolidated Appropriations Act, 2023 (CAA, 2023), related to covering and implementing intensive outpatient programs (IOP) beginning CY 2024.

CMS proposes IOP services may be furnished in hospital outpatient departments, certified mental health clinics, FQHCs, and RHCs. CMS also proposes establishing payment for intensive outpatient services provided by opioid treatment programs (OTPs) under the existing OTP benefit.

CMS proposes covered IOP services would include:

• individual and group therapy with physicians or psychologists (or other mental health professionals as authorized under State law)
• occupational therapy
• services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients
• drugs and biologicals furnished for therapeutic purposes
• individualized activity therapies that are not primarily recreational or diversionary
• family counseling
• patient training and education
• diagnostic services
• other items and services as determined by HHS.

CMS proposes to define IOP services as “a distinct and organized intensive ambulatory treatment program that offers less than 24-hour daily care other than in an individual’s home or in an inpatient or residential setting and furnishes the services” as described in statute.

To be eligible, CMS proposes that a minimum of nine hours per week of therapeutic services as evidenced in their plan of care be provided and that the individual would benefit from a coordinated program of services and require more than isolated sessions of outpatient treatment. In addition, eligible individuals would not require 24-hour care and would have an adequate support system outside of the program. A mental health diagnosis would be needed, the individual would need to be judged not to be dangerous to self or others and would have the cognitive and emotional ability to participate in and tolerate the active treatment process.

CMS would amend Part B regulations to add a reference to “intensive outpatient services” to the list of covered services when furnished as hospital or CAH services incident to a physician’s professional services.

In terms of coding and billing, CMS indicates a new condition code, condition code 92, will be used to identify intensive outpatient claims. CMS proposes that to qualify for payment for an IOP Ambulatory Payment Classification (APC), at least one service must be from the Partial Hospitalization Program (PHP)/IOP list. Those codes are 5851, 5852, 5861 or 5862 for the IOP APC or 5853, 5854, 5863, or 5864 for the PHP APC. CMS solicits comments on whether caregiver, peer support workers or discharge services/codes should be considered and included as well

Specific to FQHCs and RHCs, however, the CAA, 2023 requires that the payment amount for intensive outpatient services furnished in FQHCs and RHCs be equal to the payment amount that would have been paid for the same service furnished by a hospital outpatient department. FQHCs and RHCs currently are paid either under the FQHC PPS or RHC AIR.

For RHC IOP services, CMS proposes to pay three IOP services/day based on the hospital rate. For RHCs, payment would be for the 3 services/day rate. For IOP services furnished in FQHCs, CMS proposes the payment be based on the lesser of a FQHC’s actual charges or the rate determined for APC 5861. Both RHCs and FQHCs would need to report condition code 92 to identify intensive outpatient claims.

Additionally, for services provided through a Medicare Advantage organization, if the contract rate is lower than the amount Medicare would otherwise pay for FQHC services, FQHCs that contract with MA organizations would receive a wrap-around payment from Medicare to cover the difference.

For RHCs and FQHCs, CMS clarifies the agency will permit a mental health visit or IOP services on the same day as a medical visit.

Telehealth, Remote Monitoring, Care Management Services

CMS is proposing various policies under in the 2024 Physician Fee Schedule rule.

CMS proposes updates to reflect provisions in the CAA, 2023, including extending payment for telehealth services provided by RHCs and FQHCs through December 31, 2024, and delaying in-person requirements for mental health services provided via telehealth until January 1, 2025.

CMS is also proposing to include licensed marriage and family therapists or mental health counselors as RHC and FQHC practitioners effective January 1, 2024.

In addition, the following services can be considered an RHC or FQHC visit for Medicare payment:

• Transitional care management services
• Diabetes self-management services provided by a certified program
• Medical Nutrition Therapy sessions provided by a certified program

CMS proposes to allow RHCs and FQHCs to receive payment for Remote Physiological Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) in addition to RHC inclusive rates and FQHC per visit payments. RPM and RTM services may be billed using HCPCS G code G0511, a general care management code. Also using the general care management codes, G0511, to address increasing evidence that social determinants of health are key in successfully providing care to many populations, CMS is proposing to allow RHCs and FQHCs to receive payment for providing community health integration services and principal illness navigation services.

How CLA can help

While these changes are in proposed form now, they may provide additional options for FQHCs and RHCs to serve their patient populations. If you have questions or need assistance in setting your strategic path forward, CLA is here to help.

Thanks to CLA’s Becca Rye for her assistance in this blog post.