View all text of Subjgrp 36 [§ 405.2460 - § 405.2472]
§ 405.2464 - Payment rate.
(a) Payment rate for RHCs that are authorized to bill under the reasonable cost system. (1) Except as specified in paragraphs (d) and (e) of this section, an RHC that is authorized to bill under the reasonable cost system is paid an all-inclusive rate that is determined by the MAC at the beginning of the cost reporting period.
(2) The rate is determined by dividing the estimated total allowable costs by estimated total visits for RHC services.
(3) The rate determination is subject to any tests of reasonableness that may be established in accordance with this subpart.
(4) The MAC, during each reporting period, periodically reviews the rate to assure that payments approximate actual allowable costs and visits and adjusts the rate if:
(i) There is a significant change in the utilization of services;
(ii) Actual allowable costs vary materially from allowable costs; or
(iii) Other circumstances arise which warrant an adjustment.
(5) The RHC may request the MAC to review the rate to determine whether adjustment is required.
(b) Payment rate for FQHCs that are authorized to bill under the prospective payment system. (1) Except as specified in paragraphs (d) and (e) of this section, a per diem rate is calculated by CMS by dividing total FQHC costs by total FQHC daily encounters to establish an average per diem cost.
(2) The per diem rate is adjusted as follows:
(i) For geographic differences in the cost of inputs according to § 405.2462(c)(1).
(ii) When the FQHC furnishes services to a new patient, as defined in § 405.2462(c)(2).
(iii) When a beneficiary receives either of the following:
(A) A comprehensive initial Medicare visit (that is, an initial preventive physical examination or an initial annual wellness visit).
(B) A subsequent annual wellness visit.
(c) Payment for care coordination services. RHCs and FQHCs are paid for the non-face-to-face care management work involved in coordinating care.
(1) For Chronic Care Management (CCM) services furnished between January 1, 2016, and December 31, 2017, payment to RHCs and FQHCs is based on the physician fee schedule national non-facility payment rate.
(2) For psychiatric collaborative care model (CoCM) services furnished on or after January 1, 2018, payment is based on the average of the national non-facility PFS payment rate set for each psychiatric CoCM service and updated annually based on the PFS amounts.
(3) For CCM and general Behavioral Health Integration (BHI) services furnished between January 1, 2018, and December 31, 2020, payment is based on the average of the national non-facility PFS payment rate set for each CCM and general BHI service and updated annually based on the PFS amounts.
(4) For CCM, general BHI, and Principal Care Management (PCM) services furnished between January 1, 2021, and December 31, 2022, payment is based on the average of the national non-facility PFS payment rate set for each CCM, general BHI, and PCM service and updated annually based on the PFS amounts.
(5) For CCM, general BHI, PCM, Chronic Pain Management (CPM) services furnished between January 1, 2023, and December 31, 2023, payment is based on the average of the national non-facility PFS payment rate set for each CCM, general BHI, PCM and CPM service and updated annually based on the PFS amounts.
(6) For CCM, general BHI, PCM, CPM, Remote Physiologic Monitoring (RPM), Remote Therapeutic Monitoring (RTM), Community Health Integration (CHI), Principal Illness Navigation (PIN), and PIN—Peer Support services furnished between January 1, 2024, and December 31, 2024, the payment amount is based on a weighted average of each CCM, general BHI, PCM, CPM, RPM, RTM, CHI, PIN, and PIN—Peer Support service using the most recently available PFS utilization data.
(7) For CCM, general BHI, PCM, CPM, RPM, RTM, CHI, PIN, PIN—Peer Support, and Advance Primary Care Management services furnished on or after January 1, 2025, payment is based on the PFS national non-facility payment rate.
(d) Payment for FQHCs that are authorized to bill as historically excepted tribal FQHCs. Historically excepted tribal FQHCs are paid at the outpatient per visit rate for Medicare as set annually by the Indian Health Service for each beneficiary visit for covered services. There are no adjustments to this rate.
(e) Payment for communication technology-based and remote evaluation services. For communication technology-based and remote evaluation services furnished on or after January 1, 2019, payment to RHCs and FQHCs is at the rate set for each of the RHC and FQHC payment codes for communication technology-based and remote evaluation services.
(f) Payment for intensive outpatient services. Payment to RHCs and FQHCs is at the rate determined under § 405.2462(j).
(g) Payment for non-behavioral health telecommunication technology services. For an encounter furnished using interactive, real-time, audio and video telecommunications technology or for certain audio-only interactions in cases where the patient is not capable of, or does not consent to, the use of video technology services that are not described in § 405.2463(b)(3), payment to RHCs and FQHCs are subject to the national average payment rates for comparable services under the physician fee schedule (PFS) and costs associated with these services shall not be used in determining payments under the RHC all-inclusive rate or the FQHC prospective payment system.
(h) Payment for drugs covered as additional preventive services (DCAPS). For drugs covered as additional preventive services, as defined at § 410.64 of this subchapter, and for the administration and supplying fees for those drugs, payment to RHCs or FQHCs is 100 percent of the Medicare payment amount per § 405.2410(b) and § 410.152(l)(11) of this chapter, subject to the payment limitations described at § 410.152(o) of this chapter.