Special payments for certain classes of providers

AZ | CA | CT | DE | DC | FL | HI | IL | IN | IA | IABH | KS | KY | ME | MD | MA | MABH | MI | MN
MO | MT | NE | NEBH | NJ | NM | NY | ND | OH | PA | SC | TN | TX | UT | UTMH | VA | WA | WV | WI

"26. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)
The Contractor is encouraged to use FQHCs in Arizona to provide covered services and must comply with the federal mandates in OBRA 89 and OBRA 90. This legislation gives FQHCs the option to require state Medicaid programs to reimburse the FQHC at 100% of reasonable costs for the services delivered to Title XIX members. AHCCCSA and its contractors are required to comply with this legislation. The following payment methodology for reasonable cost reimbursement was implemented effective October 1, 1997.

If the FQHC elects reasonable cost reimbursement, the FQHC will receive a quarterly payment per Title XIX member per month from AHCCCSA. The initial capitation amount will be $1.75 PMPM statewide. In accordance with the Balanced Budget Act of 1997, this additional reimbursement will be phased out over a five-year period beginning in contract year ending 2000:
Contract Year / Phase-Out Percentage / PMPM Amount
1997 through 1999 / No phase-out / $ 1.75
2000 / 95% / $ 1.66
2001 / 90% / $ 1.58
2002 / 85% / $ 1.49
2003 / 70% / $ 1.23
2004 / 100% / $ 0.00" Arizona Contract, page 34.

"35. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT...
All GSA’s EXCEPT Maricopa and Pima: The Contractor shall reimburse hospitals for member care in accordance with AHCCCS Rule R9-22-705..." Arizona Contract, pages 37-38.

"3.28.6 Federally Qualified Health Centers/Rural Health Clinics...
In Subcontracts where the FQHC or RHC has made the election to be reimbursed on a reasonable cost basis by the State, provisions shall be included that require the subcontractor to keep a record of the number of visits by plan Members separate from Fee-For-Service Medi-Cal beneficiaries, in addition to any other data reporting requirements of the Subcontract...

In Subcontracts where a negotiated reimbursement rate is agreed to as total payment, a provision that such rate constitutes total payment shall be included in the Subcontract." California Contract, pages 38-39.

"6.6.20 FQHC and Rural Health Clinics (RHC) Contracts
A. Notwithstanding Article III, Section 3.28.4, Department Approval - Federally Qualified HMOs, Contractor shall not enter into any contract with an FQHC or RHC for provision of Covered Services to Members without prior written approval by DHS. All contracts with FQHCs or RHCs shall provide reimbursement to the FQHC or RHC on the basis of each center's or clinic's Medi-Cal interim per visit rate, applicable on the date the reimbursable services were provided, as established by DHS, unless:

1. DHS has approved in writing an alternate reimbursement methodology; or

2. The FQHC or RHC agrees to be reimbursed on an at-risk basis and such agreement is contained in the contract with the center or clinic. In contracts where a negotiated rate is agreed to as total payment, the contract shall state that such payment constitutes total payment to the entity.

B. To the extent that Indian Health Service facilities qualify as FQHCs or RHCs, the same reimbursement requirements shall apply to contracts with Indian Health Service facilities." California Contract, page 109.

"3.5 Emergency Services...
i) When a Member's primary care physician or other plan representative instructs the Member to seek emergency care in-network or out-of-network, the MCO is responsible for payment for the screening examination and for other medically necessary emergency services, without regard to whether the patient meets the prudent layperson standard described above...

k) When the MCO reimburses emergency services provided by an in-network provider, the rate of reimbursement will be subject to the contractual relationship that has been negotiated with said provider." Connecticut Contract, pages 18-19.

"7.2.4 FQHC and RHC Reimbursement...
These organizations currently serve a critical role in the Medicaid delivery system. The State is interested in ensuring that the outreach, culturally sensitive, clinical care, social support and translation services provided by these organizations are present to the same degree under the DHSSHP as they were under Fee-for-Service . In order to accomplish this, all MCOs operating in the same county as a FQHC and/or RHC, with which they intend to contract, must specify the contractual arrangements which assure that FQHC(s) and/or RHC are reimbursed for services on either a capitated basis (with appropriate adjustments for risk factors) or on a cost-related basis." Delaware RFP, pages II.49-II.50.

"2. Provider Payment Arrangements
a. For a Provider that subcontracts with a Federally Qualified Health Center (FQHC), Provider shall contract with the FQHC on the same payment terms as other providers of similar services. If the FQHC exercises it's right to be reimbursed at 100% of its reasonable costs, the District shall be responsible for the excess of reasonable cost over the amount paid to the FQHC by Provider.

b. Provider shall reimburse emergency facilities at the contracted rate for network facilities and at the current Medicaid rates for non-network facilities for the following services:
(1) the evaluation of an emergency medical condition or active labor which is required under the Emergency Treatment and Active Labor Act (Section 1867 of the Social Security Act) to determine the existence of an emergency.
(2) all medically necessary care and services furnished prior to the time that the enrollee becomes stabilized, as defined under the Act and can be appropriately transferred; and
(3) a medically appropriate transfer as defined under the Act." District of Columbia Contract, page 5.

"8. Case Management/Continuity of Care...

Public providers shall be reimbursed by the plan at the rate negotiated between the plan and the public provider or, if a rate has not been negotiated, at the lesser of either the rate charged by the public provider or the Medicaid fee-for-service reimbursement rate...

For purposes of this subsection, public providers are defined as a county health department or migrant health center funded under Section 329 of the Public Health Services Act or a community health center funded under Section 330 of the Public Health Services Act, as specified Section 381.0407, F.S. ..." Florida Contract, pages 18-22.

"4. Physician Services...
f. Pursuant to Section 4712 of the 1997 Balanced Budget Act, plans contracting with FQHCs and rural health clinic (RHCs) must reimburse those entities at rates comparable to those rates paid for similar services in the FQHC's or RHC's community..." Florida Contract, page 77.

"30.440 FQHCs and RHCs...
Health plans shall address cost related issues related to the scope of services provided by FQHCs and shall reimburse FQHCs either on a capitated (risk) basis considering adverse selection factors, or reimburse FQHCs on a cost related basis.

30.450 Provider Reimbursement
With the exception of hospice providers who must be reimbursed using Medicare methodology, the health plan may reimburse its providers and subcontractors in any manner, subject to HCFA rules…" Hawaii RFP, page 11.

"33.300 Department of Health (DOH) Services...
Vaccines for Children (VFC)...
Although the cost of the vaccines is not included in the capitated rate to the health plans, the health plan is not prohibited from allowing privately acquired vaccines and may decide who if any, and how it will reimburse for vaccines...

There will be no charge for the vaccine as the DOH health centers have access to the VFC vaccines. The DOH health center shall file a claim for reimbursement within 60 days of providing the vaccination.

To avoid duplicating the administration of the vaccine, the DOH health center shall submit to the PCP within 45 days documentation of all immunization(s) provided to QUEST members...

Adult Mental Health Division (AMHD)...
If an AMHD CMHC is part of the health plan's network and has authorization to provide services during the period of the evaluation process, the health plan shall reimburse AMHD for services provided. Otherwise, the CMHC will refer the client to the health plan for service.

If a member self-refers to CMHC, the CMHC will contact the health plan for authorization to provide services. If authorization is received, the health plan shall reimburse AMHD for services provided. Otherwise, the CMHC will refer the client to the health plan for service. If the health plan refers one of its members to one of the CMHCs for services, the plan is required to reimburse AMHD for the services...

Child and Adolescent Mental Health Division (CAMHD)...
If a CAMHD center is part of the health plan's network and has authorization to provide services during the period of the evaluation process, the health plan shall reimburse CAMHD for services provided. Otherwise, the center will refer the member to the health plan for service.

If a member self-refers to CAMHD, the center will contact the health plan for authorization to provide services. If authorization is received, the health plan shall reimburse CAMHD for services provided. Otherwise, the center will refer the client to the health plan for service. If the health plan refers one of its members to one of the centers for services, the plan is required to reimburse CMHD for the services…" Hawaii RFP, pages 35-39.

"Why is there an exception for payment of hospice providers which requires reimbursement using Medicare methodology?

ANSWER:
The State is currently having discussions with HCFA on this issue. Presently, HCFA requires the states to reimburse hospice providers using Medicare methodology." Hawaii RFP, Q&A, page 6.

"c) Will the health plan be required to reimburse for non-referral usage of the FQHC/RHCs? Are there limits or constraints to the arrangement that can be made for reimbursing FQHCs on a cost related basis?

ANSWER: ...
If a FQHC or RHC contracts with the health plan, the FQHC or RHC is responsible for meeting the requirements of the contract. There are no limits or constraints to the arrangement that can be made for reimbursing FQHCs." Hawaii RFP, Q&A, page 6.

"(11) Any subcontract between the Contractor and a Federally Qualified Health Center (‘FQHC’) or a Rural Health Clinic (‘RHC’) shall be executed in accordance with 1902(a)(13)(C) and 1903(m)(2)(A)(ix) of the Social Security Act, as amended by the Balanced Budget Act of 1997 (Public Law 105-33) and shall provide payment that is not less than the level and amount of payment which the Contractor would make for the Covered Services if the services were furnished by a Provider which is not an FQHC or RHC…" Illinois HMO Contract, pages 49-50.

"4.4.2.5 Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs)...
OMPP will provide a supplemental payment at least quarterly to the FQHC and RHC to bring reimbursement up to 100% of reasonable costs. In order to calculate the supplemental payment, the amount paid directly to the FQHC or RHC by the MCO for services provided to enrollees will be subtracted from 100% of reasonable costs. MCOs must submit to OMPP, or its designee, at least quarterly, the amount paid by the MCO to the FQHC or RHC for services provided to MCO enrollees in order for OMPP to calculate the supplemental payment due to the FQHC or RHC. Beginning in fiscal year 2000, the amount that the OMPP will pay to bring the FQHC or RHC up to reasonable cost will be phased down in accordance with the Balanced Budget Act of 1997 (P.L.105-33).

The MCO shall identify to the State any performance incentives offered to the FQHC or RHC. All such FQHC and RHC incentives which accrue during the contract period that are related to the cost of providing FQHC-covered or RHC-covered services to RBMC enrollees shall be included along with any fee-for- service and/or capitation payments in the determination of the amount of direct reimbursement paid by the MCO to the FQHC or RHC.

The MCO must provide assurances that it is paying the FQHC or RHC at a rate that is not less than the level and amount of payment the MCO would make for the services if the services were furnished by a provider which is not a FQHC or RHC. The MCO shall provide supporting documentation of its rates at OMPP's request." Indiana RFP, pages 4-8 - 4-9.

"4.2.5.3. Contracts with Federally Qualified Health Clinics (FQHC) and Rural Health Clinics (RHC)
The HMO is encouraged to contract with RHCs and FQHCs in their Enrollment Area...
The HMO's payments for services provided by a RHC or FQHC shall be no less than the HMO's customary payment for any other Provider of similar services in the same geographic area." Iowa Contract, page 25.

IABH

"44.0 NETWORK MANAGEMENT...
In managing the provider network, the Contractor shall also meet the following requirements: ...
5) The Departments reserve the right to set minimum reimbursement rates for community mental health centers and DPH funding allocation for substance abuse..." Iowa Behavioral Health Contract, page 29.

"53.4 PAYMENTS BY THE CONTRACTOR OF DPH FUNDS
The Contractor will provide prospective reimbursement each month to contracted DPH-funded substance abuse network providers for the services covered by this contract." Iowa Behavioral Health Contract, page 39.

"Payment for Emergency Room Services (Section 5.9.4 of the RFP)...

For emergency room services provided for psychiatric or substance abuse reasons by network or non-network provider, the Contractor must:
* provide a minimum triage fee to the hospital regardless of whether the facility notifies the contractor; the triage fee shall be no less than is paid through the FFS Medicaid program
* reimburse the facility for emergency room services provided, contingent upon the facility's compliance with notification policies..." Iowa Behavioral Health Contract, page 90.

"G. FEDERALLY QUALIFIED HEALTH CENTERS (FQHCs)...
Federally Qualified Health Centers which elect to be reimbursed on a negotiated risk capitation basis are not entitled to reasonable cost reimbursement. Unless the FQHC agrees, in advance, to accept a capitated rate from the HMO, the FQHC shall have a cost settlement performed by SRS which shall result in cost reimbursement being received by the FQHC. SRS shall perform the cost settlement and any payment or recoupment shall be between the FQHC and SRS only…

When subcontracting with an FQHC which demands reasonable cost, the HMO must reimburse the FQHC at 80% of the encounter rate currently being paid by SRS. Cost reports to document the FQHC payment will need to be submitted quarterly if the FQHC is paid at cost. These reports must be in such formats as to prove that the rates paid are equivalent, whether on a fee-for-service or encounter basis. The FQHC must choose to be cost reimbursed on a prospective basis rather than a retrospective basis." Kansas Contract, pages 11-12.

"F. FEDERALLY QUALIFIED HEALTH CENTER (FQHC) AND RURAL HEALTH CENTER (RHC) PAYMENT METHODOLOGY CHANGE. Contract Section IIG is amended by replacing the language stated therein with the following:
Payment for FQHC and RHC services by MCO shall be at the same rate MCO pays Non-RHC providers of like services. MCO agrees to provide to SRS a monthly payment history for all network and non-network FQHCs and RHCs providing services to MCO for Medicaid members for that month. The monthly payment history shall document each service provided for MCO by each FQHC and RHC, and shall specify the price for each of those services." Kansas Contract, Amendment One.

"VII. Financial Conditions...
G. Payment of Federally Qualified Health Centers ('FQHC') and Rural Health Clinics
The Contractor shall pay FQHC(s) and Rural Health Clinics in its Contractor's Network on either a capitated basis, with appropriate adjustments for risk factors, or on a cost-related basis. A description of the payment method shall be submitted to the Department for review and approval prior to implementation.

The Contractor shall provide for a transition payment for services provided to FQHC's and Rural Health Clinics (RHCs) by managed care organizations so that the payment MCOs provide to FQHCs and RHCs is not less than the level and amount of payment the Contractor would make for the services if they were furnished by another provider.

H. Payment of Teaching Hospitals
In establishing payments for teaching hospitals in its Contractor's network, the Contractor shall recognize costs for graduate medical education, including adjustments required by KRS 205.565." Kentucky Contract, pages 30, 37.

"11. VD Screening Services. In the event an out-of-network provider bills the Contractor for VD Screening Services provided to an Enrollee in Contractor's Health Plan, the Contractor shall reimburse the provider at no lower than the prevailing Medicaid fee-for-service rate." Maine Contract, page 25.

"10.09.64.06...
.06 Access and Capacity: Benefits and Appointments.
An MCO applicant shall include in its application the following information or descriptions: …
E. Documentation of the applicant's preparedness to collaborate with providers of self-referral services, and reimburse at the Department's established fee-for-service rate, for permissible self-referred services, including:
(1) Family planning services as specified in COMAR 10.09.65.20A(2), (6), and (7);
(2) School-based clinic services as specified in COMAR 10.09.68;
(3) Pregnancy-related services under circumstances specified in COMAR 10.09.67.28C;
(4) Initial medical examination services to children in State-supervised care;
(5) Annual diagnostic and evaluation services (DES) for individuals diagnosed with HIV/AIDS; and
(6) Renal dialysis services
(7) OT, PT, audiology and speech therapy for enrollees under 21 years old." Maryland COMAR 10.09.64.06.

"10.09.65.02...
H. An MCO:
(4) Shall pay Maryland hospital providers on the basis of rates approved by the Maryland Health Services Cost Review Commission (HSCRC)." Maryland COMAR 10.09.65.02.

"10.09.65.16...
(6) Historic Provider Contract.
(a) Subject to the reimbursement requirement for FQHCs in Regulation .21 of this chapter, upon the historic provider's assignment to an MCO, the MCO shall offer the historic provider a contract with terms that are substantially equivalent to the MCO's contracts with similarly qualified non-assigned providers in the same or similar practice categories." Maryland COMAR 10.09.65.16.

".21 MCO Payment to Federally Qualified Health Centers (FQHC).
A. An MCO shall reimburse an FQHC with which it subcontracts on either a capitated or a fee-for-service basis, as follows:
(1) If reimbursement is made on a capitated basis, the MCO shall make appropriate adjustments for risk factors in its rate; or
(2) If reimbursement is made on a fee-for-service basis, the MCO payment shall be cost-related, such that an MCO shall take into account the FQHC's costs for the unit of service, but is not required to pay 100 percent of an FQHC's reasonable allowable costs, when negotiating a payment rate." Maryland COMAR 10.09.65.21.

"Section 2.13 Financial Requirements...
To meet this general requirement, the Contractor, at a minimum, shall: ...
H. In accordance with 42 USC 139u-2(a)(13)(C), reimburse Federally -Qualified Health Centers (FQHCs) for MCO Covered Services provided by FQHCs at the specified percentage of the FQHC's reasonable cost based on the Division's fee schedule relative to FQHCs. This percentage, unless otherwise changed in law shall be FY 1999, 100 percent; for FY 2000, 95 percent; for FY 2001, 90 percent; for FY 2002, 85 percent; and for FY 2003, 70 percent…" Massachusetts Contract, pages 91-92.

"Section 4.3 Payment Methodology
A. Capitation Rate Development...
3. In accordance with 42 USC 1396u-2(a)(13)(C), in determining the Capitation Rate for all Rating Categories, the Division shall include for MCO Covered Services provided by Federally-Qualified Health Centers (FQHCs), no less than the specified percentage of the FQHC's reasonable cost based on the Division's fee schedule relative to FQHCs. This percentage, unless otherwise changed in law, shall be for FY 1999, 100 percent; for FY 2000, 95 percent; for FY 2001, 90 percent; for FY 2002, 85 percent; and for FY 2003, 70 percent…" Massachusetts Contract, pages 108-109.

MABH

"B. Reimbursement Rules for Designated Emergency Programs (DEPs) / Emergency Screening Programs (ESPs)
1. In accordance with Section 5.2 A of Appendix A to this Contract, the Contractor shall utilize DMH Service Compensation Payments to pay ESPs/DEPS, whichever is-applicable, for Covered Services rendered to DMH Acute Care Consumers who are not Recipients or Excluded Recipients subject to the following limitations and requirements: ...
b. The Contractor shall reimburse ESPs/DEPs for the cost of services rendered to those DMH Acute Care Consumers who have TPL whether or not their TPL benefits have been exhausted in an amount not to exceed the difference between the applicable ESP/DEP reimbursement rate as negotiated by the Contractor and TPL receivable, if any...
d. The Contractor shall utilize DMH Compensation Rate Payments to reimburse ESPs/DEPs in an amount not to exceed applicable reimbursement rates as approved by the Division only for services rendered to DMH Acute Care Consumers without TPL, even if benefits have been exhausted, and only to the extent the costs of services exceed any and all sliding fee scale receivables...

C. Reimbursement Rules for DMH Covered Services for DMH Acute Care Consumers
1. In accordance with Section 5.2.A of this Appendix A to the Contract, the Contractor shall utilize DMH Service Compensation Rate Payments to reimburse Network Providers and non-Network providers for DMH Covered Services as described in Appendix C to this Contract for DMH Acute Care Consumers who are not Recipients or Excluded Recipients subject to the following limitations and requirements:
a. For DMH Covered Services rendered to DMH Acute Care Consumers who are not Recipients, the Contractor shall require Network Providers and non-Network providers to bill TPL, the Free Care Pool in accordance with applicable law, and DMH Acute Care Consumers according to a sliding fee scale. By July 1, 1996, the Contractor shall submit for the Division's review and approval a sliding fee scale in accordance with this section...
c. The Contractor shall not reimburse Network Providers and non-Network providers for DMH Covered Services to any DMH Acute Care Consumer with TPL; whether or not the DMH Acute Care Consumer's TPL benefits have been exhausted.
d. The Contractor shall utilize DMH Service Compensation Rate Payments to reimburse Network Providers and non-Network providers in an amount not to exceed applicable Provider reimbursement rates as approved by the Division only for DMH Covered Services rendered to DMH Acute Care Consumers without TPL, even if benefits have been exhausted, and only to the extent the costs of DMH Covered Services exceed any and all Free Care Pool and/or sliding fee scale receivables...
f. The Contractor shall require Network Providers and non-Network providers to apply any uncollectible self-pay receivables to bad debt and to bill the Free Care Pool if in accordance with applicable law." Massachusetts MH/SAP Contract, Appendix A, pages 53-55.

"Section 5.6: Free Care Reimbursement to Former Replacement Units...
(b) Payments made by the Contractor to the Selected RUs pursuant Free Care Agreements shall be funded from the Service Compensation Rate for DMH Covered Services detailed in Section 5.2 of Appendix A to the Contract; provided, further, that the Contractor shall not be responsible in any manner for payment of any claims submitted by Selected RUs for services provided pursuant to a Free Care Agreement in excess of the Service Compensation Rate payments paid to the Contractor..." Massachusetts MH/SAP Contract, Amendment 1, pages 21-22.

"F. Performance Incentives, Penalties, and Initiatives...
4. Section 5.2.AA.1. shall be amended by adding at the end thereof the following new Section 5.2.AA.l.d.:

Section 5.2.AA.l.d.: For the fourth Contract Year, the portion of the Compensation Rate payments used to reimburse providers of Inpatient Mental Health Services and Observation/Holding Beds to Group B DMH Acute Care Consumers and Group C Acute Care Consumers, combined, does not exceed the amount of $2,768,808; provided, however, that in the event that the Contractor's expenditures for Group B DMH Acute Care Consumers for Inpatient Mental Health Services and Observation/Holding Beds exceeds $2,768,808 in FY 00, the Contractor shall be reimbursed for said expenditures." Massachusetts MH/SAP Contract, Amendment 5, pages 9-10.

"BENEFIT ADVOCACY
15. Homeless Shelters and Detoxification Facilities...
The Contractor shall reimburse participating shelters and detoxification facilities a $30 per application incentive, and shall receive an amount equal to 15% of each $30 application incentive paid." Massachusetts MH/SAP Contract, Amendment 6, page 9.

"II-I SPECIAL COVERAGE PROVISIONS...
5. Federally Qualified Health Centers (FQHCs)...
For services furnished on or after October 1, 1997, FQHCs are entitled, pursuant to the Social Security Ace, to reasonable cost-based reimbursement as subcontractors of section 1903 (m) organizations. Section 4712(b)(2) requires that rates of payments between FQHCs and Managed Care Organizations (Health Plans) shall not be less than the amount of payment for a similar set of services with a non-FQHC. States are required to make supplemental payments, at least on a quarterly basis, for the difference between the rates paid by section 1903 (m) organizations (Health Plans) and the reasonable cost of FQHC subcontracts with the 1903 (m) organization (Health Plans). Beginning in Fiscal Year (FY) 2000, the difference states will be required to pay begins to phase down from 100 percent: specifically, 95 percent of reasonable cost in FY 2000, 90 percent in FY 2001, 85 percent in FY 2002, and 70 percent in FY 2003..." Michigan Contract, pages 22, 25-26.

"Section 4.4. Payment for IEP and IFSP Services. Beginning July 1, 1999, the HEALTH PLAN shall be responsible for Medically Necessary MA services that are covered by this Contract, identified in an Enrollee's Individual Education Plan (IEP) or Individual Family Service Plan (IFSP), and provided by school districts… In determining the amount of the claim, the HEALTH PLAN shall use the charge by a school district or the STATE's MA fee schedule for each claimed service, whichever is lesser. The STATE will pay the claim in a lump sum 30 days after the submission of the claim…" Minnesota Contract, page 40.

"Section 9.2.7. FQHCs and RHCs Contracting Requirements. If the HEALTH PLAN negotiates a provider agreement or subcontract with a federally qualified health center (FQHC) as defined in Section 1905(1)(2)(B) of the Social Security Act, 42 U.S.C. Section 1396d(l)(2)(B), or a rural health clinic (RHC) as defined in 42 C.F.R. 440.20, the negotiated payment rates must be comparable to the rates negotiated with other subcontractors who provide similar health services… The HEALTH PLAN is not required to pay any settle-up payments in addition to the negotiated payment rate.

Section 9.2.8. Community Clinic, Community Mental Health Centers, and Community Health Services Agencies Subcontracting Requirements. The HEALTH PLAN shall contract with nonprofit community clinics, community mental health centers, or community health services agencies to provide services to Enrollees… if the clinic or agency agrees to payment rates that are competitive with rates paid to other HEALTH PLAN providers for the same or similar services…" Minnesota Contract, pages 84-85.

"Section 9.2.19. Nursing Facility Subcontracting.

A. The HEALTH PLAN may develop contracts and negotiate rates with Nursing Facilities. The HEALTH PLAN shall include in its payment arrangement for Nursing Facility services provisions that require the Nursing Facilities to cooperate with the STATE procedures for collection of Spenddowns.

B. If the HEALTH PLAN authorizes Nursing Facility care in a Nursing Facility where the HEALTH PLAN does not have a contracted rate, the HEALTH PLAN shall pay the Nursing Facility the appropriate Medical Assistance rate…" Minnesota Contract, page 87.

"2.3.7 Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs): If the health plan includes subcontracted FQHCs or RHCs in its network, the FQHC or RHC can elect to be reimbursed on a negotiated risk capitation basis or demand reasonable costs from the state agency and any differential payment paid by the state agency…

3) The FQHC/RHC must bill its usual and customary amount for all payor classes. The health plan must include the billed amount when the health plan submits the encounter claims to the state agency." Missouri RFP, pages 32-33.

"MEDICAID INTERIM RATE - the rate MEDICAID pays for each visit of a Medicaid RECIPIENT to a federally qualified health center or certified rural health clinic. The rate is PROVIDER specific and updated annually." Montana Contract, page 28.

"2.4.2 Participating Providers: ...
B. Providers Contracts Must be Extended to or Contractor Must Allow Access to: ...
2) Federally Qualified Health Centers (FQHCs) and Rural Health Clinics RHCs: ...

At a minimum, the CONTRACTOR must reimburse an FQHC or RHC PARTICIPATING PROVIDER either the Medicaid interim rate for each medically necessary ENROLLEE visit to the FQHC or RHC or the same payment per ENROLLEE or service offered to the CONTRACTOR'S other PRIMARY CARE PROVIDERS. The DEPARTMENT is responsible for paying the shortfall to the FQHC/RHC or recouping the excess from the FQHC/RHC for the difference between the amount reimbursed by the CONTRACTOR and the reasonable cost to the FQHC or the RHC to provide the covered service...

3) Public Health Clinic Access...
At a minimum the CONTRACTOR shall reimburse such public health clinics at the Medicaid rate…" Montana Contract, pages 36-37.

"13.48.1 Payment of Emergency Services Provided to NHC Clients: The plan has no obligation to pay for emergency services unless the provider of the emergency services submits a bill within ninety (90) calendar days of the date services were provided.

If the plan has reasonable basis to believe that any covered services that are claimed to be emergency services were not in fact emergency services, payment may be denied for the services; provided that, within ninety (90) calendar days of receipt of a claim for payment:

(a) The provider of the services is notified of the decision to deny payment, the basis for that decision, and the provider’s right to appeal that decision by requesting a hearing (See 482 NAC); and

(b) The client is notified of the decision to deny payment, the basis for that decision, and the client’s right to appeal (See 482 NAC).

13.48.2 Triage or Screening Fee: The plan shall provide a triage or medical screening fee to determine if a medical emergency exists." Nebraska Contract, page 97.

"13.50 Federally Qualified Health Centers (FQHC): Each plan shall contract with any FQHC located within the designated coverage area or otherwise arrange for the provision of FQHC services. If an FQHC is reimbursed by the plan on a fee-for-service basis, it cannot pay less for those services than it pays other providers. FQHC’s that elect to be reimbursed on a negotiated risk basis are not entitled to reasonable cost reimbursement.

If the FQHC requests reasonable cost reimbursement, the plan must reimburse the FQHC at the same rate it reimburses its other subcontractors. A plan that contracts with a FQHC shall report to the Department the total amount paid to each FQHC as specified in the contract. FQHC payments include direct payments to a medical provider who is employed by the FQHC." Nebraska Contract, page 99.

NEBH

"11.52.5 Emergency Services: The PHP shall ensure that: ...
The PHP shall reimburse MH/SA providers, network and out-of-network, for appropriate medical screening performed during an emergency room visit. The payment of claims for Medicaid-coverable services to out-of-network MH/SA providers are subject to the requirements in this contract…" Nebraska Behavioral Health Contract, pages 64-65.

"11.54.2 Payment for Emergency Services: The PHP has no obligation to pay for emergency services unless the provider of the emergency services submits a bill within the timeframe specified by the PHP. (See Section 11.55.1 of this contract which addresses when emergency services are covered by the PHP.)" Nebraska Behavioral Health Contract, page 67.

"11.56 Federally Qualified Health Centers (FQHC): If MH/SA services are provided by the FQHC, the PHP shall contract with an FQHC or otherwise arrange for the provision of FQHC services. If an FQHC is reimbursed by the PHP on a fee-for-service basis, it cannot pay less for those services than it pays other MH/SA providers. FQHC’s electing to be reimbursed on a negotiated risk basis are not entitled to reasonable cost reimbursement. If the FQHC requests reasonable cost reimbursement, the PHP must reimburse the FQHC at the same rate it reimburses its other subcontractors. A PHP that contracts with a FQHC shall report to the Department the total amount paid to each FQHC as specified in the contract. FQHC payments include direct payments to a MH/SA provider who is employed by the FQHC." Nebraska Behavioral Health Contract, page 69.

"ARTICLE 3
COMPENSATION/CAPITATION...
3.9... The contractor may pay the FQHCs on a fee-for-service or capitated basis. The contractor shall make payments for primary care equal to, or greater than, the average amounts paid to other primary care providers, and for non-primary care service, payments equal to, or greater than, the average amounts paid to other non-primary care providers for equivalent services. Under Title XIX, an FQHC shall be paid reasonable cost reimbursement by the DMAHS through fiscal year 1999, after which the percentage rate will decrease annually until fiscal year 2004, when the payment requirement will be repealed…DMAHS will reimburse the FQHC for the difference (i.e., difference between the determined reasonable cost and the payments by the contractor to the FQHC are less than reasonable costs. DMAHS will recoup payments from the FQHC in excess of reasonable costs…" New Jersey Contract, pages 30-32.

"2.C.8 Federally Qualified Health Centers ('FQHCs'): ...
The CONTRACTOR must offer FQHCs and RHCs terms and conditions, including reimbursement, that are at least equal to those offered to other providers of comparable services." New Mexico Contract, page 29.

"12. Article 5, Section 5.E.4 is amended as follows:
5.E.4 Reimbursement for Emergency Services
The MCO shall insure that acute general hospitals are reimbursed for emergency services which they provide because of federal mandates such as the 'anti-dumping' law in the Omnibus Budget Reconciliation Act of 1989, P.L. 101-239 and 42 U.S.C. Section 1395 dd (1867 of the Social Security Act).

5.E.4.a If the screening examination leads to a clinical determination by the examining physician that an actual emergency medical condition exists. the MCO must pay for both the services involved in the screening examination and the services required to stabilize the patient.

5.E.4.b. The MCO is required to pay for all emergency services which are medically necessary until the clinical emergency is stabilized...

5.E.4.d When the member's primary care physician or other MCO representative instructs the member to seek emergency care in network or out of network, the MCO is responsible for payment for the medical screening examination and for other medically necessary emergency services, without regard to whether the member meets the prudent layperson standard." New Mexico Contract, Amendment #1, pages 4-5.

"PROVIDER NETWORK AND AGREEMENTS...
21.20 Federally Qualified Health Centers (FQHCs)...
However, when an FQHC is part of the provider network (voluntary or mandatory counties) the Provider Agreement must include a provision whereby the Contractor agrees to compensate the FQHC for services provided to Enrollees at a payment rate that is not less than the level and amount for a similar set of services which the Contractor would make to a provider that is not an FQHC…" New York Contract, pages 21-1-21-10.

"Medicaid Interim Rate - The rate Medicaid pays for each visit of a Medicaid recipient to a federally qualified health center or certified rural health clinic. The rate is provider specific and updated annually by the Department." North Dakota Contract, Attachment C, page 5.

"2.4. Family Planning Service Access and Confidentiality
(1)… The Contractor shall make a reasonable effort to contract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and shall reimburse providers for all family planning services regardless of whether they are rendered by a participating provider. At a minimum the contractor shall pay providers of family planning services at the Medicaid rate. The Contractor may require family planning providers to submit claims or reports in specified formats before reimbursing services." North Dakota Contract, Attachment C, page 10.

"2.5 Public Health Clinic Access...
The Contractor shall also make a reasonable effort to contract with all county public health clinics for these and other services. At a minimum, the Contractor shall reimburse such public health clinics at the Medicaid rate…" North Dakota Contract, Attachment C, page 11.

"2.21 Participating Providers...
The Contractor shall offer federally qualified health centers (FQHCs) or rural health clinics (RHCs) which serve recipients in the enrollment area terms and conditions, excluding reimbursement, at least as favorable as those offered to other primary care providers...
At a minimum, the Contractor must pay an FQHC or RHC participating provider either the Medicaid interim rate for each medically necessary enrollee visit to the FQHC or RHC or make the same capitation payment per enrollee offered to the Contractor's other primary care providers. The Department is responsible for paying the shortfall to the FQHC or RHC or recouping the excess from the FQHC or RHC for the difference between the amount paid by the Contractor and the reasonable cost to the FQHC or the RHC to provide the covered service.

The Contractor is not responsible for disproportionate share payments to hospitals…" North Dakota Contract, Attachment C, pages 22-23.

"Federally Qualified Health Center (FQHC) Services...
If the MCP contracts with an FQHC, it must reimburse the FQHC on either a capitated basis with appropriate adjustments for adverse selection factors, or on a cost-related basis. MCPs who decide to meet the FQHC requirement through contracting must provide copies of signed subcontracts between the MCP and the FQHC(s). These subcontracts must specifically describe the payment methodology to be employed..." Ohio RFP, pages 27-28.

"P. PAYMENTS TO AND FROM HMOS...
2. Payments to Providers...
e. FQHCs
The Department has included adequate amounts in projected fee-for service costs to reflect payments to FQHCs at one hundred percent (100%) of reasonable costs. As such, the Department shall determine a rate for each FQHC that reflects one hundred percent (100%) of reasonable costs. The HMO must pay each FQHC at rates that reflect one hundred percent (100%) of reasonable cost, if the FQHC requires reimbursement at this rate. However, the HMO may negotiate a capitated rate with the FQHC which is lower than one hundred percent (100%) of reasonable cost, providing the FQHC agrees to the negotiated, capitated rate…" Pennsylvania RFP, pages 90-93.

"2 FINANCIAL MANAGEMENT...
2.2 Payment to Federally-Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)
2.2.1 The capitation payment to the Contractor excludes 100% of the units and expenditures applicable to the FQHCs and RHCs.
2.2.2 The Contractor shall not make payment to a FQHC/RHC which is less than the level and amount of payment which the Contractor makes for similar services if the services were furnished by a provider which is not a FQHC or RHC.
2.2.3 Contractor may elect to make payment to the FQHC/RHC provider at a level and amount that exceeds the minimum requirements described in § 2.2.2, above, and such payment may equal the level and amount of payment that the FQHC/RHC provider would have been entitled to receive as reimbursement from the South Carolina Medicaid Program if the service had been furnished to a Medicaid recipient who was not enrolled with a managed care provider at the time the service was rendered.
2.2.4 To the extent that payments by Contractor to any FQHC or RHC are at a level and amount that require DHHS to make supplemental payments under the terms of §1902(a)(13)(C) of the Social Security Act [as amended by the Balanced Budget Act of 1997], DHHS shall be responsible for making such payments to the FQHCs or RHCs...

2.4 Ancillary Services Provided at the Hospital
Ancillary services which are provided by the hospital include, but are not limited to, radiology; pathology; neurology; and anesthesiology. When the Contractor's network providers/subcontractors authorize these services (either inpatient or outpatient) the Contractor shall reimburse the professional component of these services at the Medicaid fee-for-service rate, unless another reimbursement rate has been previously negotiated…" South Carolina Contract, pages 4-5.

"5.1 Subcontract Requirements…
5.1.37 For any subcontract with an FQHC/RHC, the Contractor shall adhere to federal requirements for reimbursement for FQHC/RHC services. The subcontract shall specify the agreed upon payment from the Contractor to the FQHC/RHC. Any bonus or incentive arrangements made to the FQHCs/RHCs associated with Medicaid HMO members must also be specified to SCDHHS. The subcontract shall specify that the Contractor shall submit the name of each FQHC/RHC and the number of Medicaid encounters paid to each FQHC/RHC by month of services to the SCDHHS for reasonable cost based reconciliation purposes...

5.1.39 The Contractor shall not make payment to FQHC/RHC which is less than the level and amount of payment which the Contractor makes for similar services if the services were furnished by provider which is not a FQHC or RHC." South Carolina Contract, pages 29, 33.

"2-3. Benefit/Services Requirements and Limitations…
q. Federally Qualified Health Centers (FQHCs) and Other Safety Net Providers...
If the CONTRACTOR utilizes FQHCs for services, the CONTRACTOR is required to address cost issues related to the scope of services provided by FQHCs and shall reimburse FQHCs either on a capitated (risk) basis considering adverse selection factors or reimburse FQHCs on a fee-for-service, cost-related basis…" Tennessee Contract, pages 7-26.

"6.5 EMERGENCY SERVICES
6.5.1 HMO must pay for the professional, facility, and ancillary services that are medically necessary to perform the medical screening examination and stabilization of HMO Member... rendered by either HMO's in-network or out-of-network providers. HMO may elect to pay any emergency services provider an amount negotiated between the emergency provider and HMO, or a reasonable and customary amount determined by the HMO...

6.5.4 Medical Screening Examination... HMO must pay for the emergency medical screening examination required to determine whether an emergency condition exists, as required by 42 U.S.C. 1395dd. HMOs must reimburse for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services.

6.5.5 Stabilization Services... HMOs must reimburse for physician's services and hospital's emergency services including the emergency room and its ancillary services…" Texas Contract, page 37.

"6.7 FAMILY PLANNING - SPECIFIC REQUIREMENTS...
6.7.3 Provider Standards and Payment... HMO will reimburse family planning agencies and out-of-network family planning providers the Medicaid fee-for service amounts for family planning services, including medically necessary medications, contraceptives, and supplies." Texas Contract, page 40.

"7.14 RURAL HEALTH PROVIDERS...
7.14.3 HMO must reimburse rural hospitals with 100 or fewer licensed beds in counties with fewer than 50,000 persons for acute care services at a rate calculated using the higher of the prospective payment system rate or the cost reimbursed methodology authorized under the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). Hospitals reimbursed under TEFRA cost principles shall be paid without the imposition of the TEFRA cap.

7.14.4 HMO must reimburse physicians who practice in rural counties with fewer than 50,000 persons at a rate using the current Medicaid fee schedule, including negotiated fee-for-service.

7.15 FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS) AND RURAL HEALTH CLINICS (RHCS)

7.15.2 FQHCs or RHCs will receive a cost settlement from TDH and must agree to accept initial payments from HMO in an amount that is equal to or greater than HMO’s payment terms for other providers providing the same or similar services...

7.15.2.2 For FQHCs, TDH will determine the amount of the interim settlement based on the difference between: an amount equal to the number of Medicaid allowable encounters multiplied by the rate per encounter from the latest settled FQHC fiscal year cost report, and the amount paid by HMO to the FQHC for the quarter. For RHCs, TDH will determine the amount of the interim settlement based on the difference between a reasonable cost amount methodology provided by TDH and the amount paid by HMO to the RHC for the quarter. TDH will pay the FQHC or the RHC the amount of the interim settlement, if any, as determined by TDH or collect and retain the quarterly recoupment amount, if any.

7.15.2.3 TDH will cost settle with each FQHC and RHC annually, based on the FQHC or the RHC fiscal year cost report and the methodology described in Article 7.15.2.2. TDH will make additional payments or recoup payments from the FQHC or the RHC based on reasonable costs less prior interim payment settlements.

7.15.2.4 Cost settlements for RHCs, and HMO’s obligation to provide RHC reporting described in Article 7.15, are retroactive to October 1, 1997." Texas Contract, pages 70-72.

"Article VIII - Payments...
B. Payment Amounts
3. Federally Qualified Health Centers (FQHCs)
If the CONTRACTOR enters into a subcontract with the Federally Qualified Health Center (FFQHC), the CONTRACTOR will reimburse the FQHC an amount equal to what the CONTRACTOR pays comparable providers that are not FQHCs. The FQHC may be entitled to additional reimbursement for the DEPARTMENT for the difference between CONTRACTOR payments to the FQHC and the FQHC's reasonable costs... If the CONTRACTOR has capitated arrangement with an FQHC, the DEPARTMENT is not responsible to either the CONTRACTOR or the FQHC for 100% of the FQHC's reasonable costs..." Utah Contract, Attachment B, pages 36-37.

UTMH

"9. The CONTRACTOR must attempt to subcontract with the Federally Qualified Health Center(s) (FQHC) in the CONTRACTOR's area for the provision of outpatient mental health services covered under this Contract. The CONTRACTOR will reimburse the FQHC an amount equal to what the CONTRACTOR pays comparable providers that are not FQHCs. The FQHC may be entitled to additional reimbursement from the DEPARTMENT for the difference between CONTRACTOR payments to the FQHC and the FQHC's reasonable costs. The cost audits will be conducted by the DEPARTMENT. If the CONTRACTOR has a capitated arrangement with and FQHC, the DEPARTMENT is not responsible to either the CONTRACTOR or the FQHC for 100% of the FQHC's reasonable costs." Utah Mental Health Contract, page 13.

"ARTICLE I - DEFINITIONS...
(Initial) Emergency Room Assessment Fee (Triage Fee) - The fee paid for all non-emergency claims for services delivered in the emergency room. The fee has two (2) components: a facility component and a physician component. The facility component is reimbursed using an all inclusive fee which approximates the fee for an intermediate emergency room visit. The physician component is reimbursed using an all-inclusive fee which approximates the fee for a brief physician office visit for a new patient." Virginia Contract, page 8.

"6. Emergency Services...
The Contractor shall reimburse in-network and out-of-network providers rendering such services in an emergency department, at a minimum, an initial emergency room assessment fee ("triage fee").
In the absence of an agreement otherwise, this triage fee will be set in accordance with the Medicaid fee schedule...

The Contractor shall cover all emergency services as defined in Article II provided by out-of-network providers. In the absence of an agreement otherwise, all claims for emergency services shall be reimbursed at the applicable Medicaid fee-for-service rate in effect at the time the service was rendered...

When emergency services are provided to an enrollee of the Contractor, the organization's liability for payment is determined as follows:

Presence of a Clinical Emergency...
The Contractor must pay for both the services involved in the screening examination and the services required to stabilize the patient.

Emergency Services Continue Until the Patient Can be Safely Discharged or Transferred - The Contractor shall pay for all emergency services which are medically necessary until the clinical emergency is stabilized...

Absence of a Clinical Emergency - If the screening examination leads to a clinical determination by the examining physician that an actual emergency medical condition does not exist, the Contractor shall pay for all services involved in the screening examination if the presenting symptoms (including severe pain) were of sufficient severity to have warranted emergency attention under the 'prudent layperson' standard, as defined herein...

Referrals - … HMO shall be responsible for payment for the medical screening examination and for other medically necessary emergency services, without regard to whether the patient meets the 'prudent layperson' standard, as defined herein.

The Contractor shall cover those medical examinations performed in emergency departments for enrolled children as part of a child protective services investigation. In the absence of an agreement otherwise, these services shall be reimbursed at the applicable Virginia Medicaid fee-for-service rate in effect at the time the service was rendered." Virginia Contract, pages 38-40.

"D. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) & RURAL HEALTH CLINICS (RHC)
The Contractor and the Department shall comply with the terms of Section 1903 (m)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1396 b (m)(2)(A)(ii).

Prior to FQHC or RHC contract signature, the Contractor must notify the Department of the type of financial arrangement negotiated with FQHCs or RHCs. The Contractor must establish the following type of contractual arrangement:
a. If the FQHC or RHC accepts partial capitation or another method of payment at less than full risk for patient care (i.e., primary care capitation, fee-for-service), the Department will provide a cost settlement to the FQHC or RHC so that the FQHC or RHC is paid the maximum allowable of reasonable costs, i.e. 100% for Federal Fiscal Year (FFY) 1999. 95% for FFY 2000. Etc… as provided under 1902 (a)(13)c. In this instance, the Department shall cover the difference between the amount of direct reimbursement paid to the FQHC or RHC by the Contractor and the FQHC's or RHCs reasonable costs for services provided to Contractor patients. This arrangement applies only to patient care costs of Options enrollees...

The Contractor must provide assurances that it is paying the FQHC or RHC at a rate that is comparable to the rate it is paying other providers of similar services and the Contractor shall provide supporting documentation at the Department's request." Virginia Contract, page 93.

"4.9 Self-Referral to Family Planning Clinics and Health Departments: Members may self-refer for certain services which are also covered services under the agreement...
If a member self-refers for these services, DSHS is responsible for payment under separate service agreements. If a provider participating with the Contractor provides, or refers a member to a health department or family planning clinic, for any of these services, the Contractor is responsible for payment." Washington Contract, pages 17-18.

"7.5 Payment to FQHCs/RHCs: The Contractor shall not pay a federally qualified health center or a rural health clinic less than the Contractor would pay non-FQHC/RHC providers for the same services (42 USC 1396 (m)(2)(A)(ix))." Washington Contract, page 36.

"3.8 Payment for Emergency Services
When emergency services are provided to an enrollee of the Managed Care Plan, the Managed Care Plan's liability for payment is determined as follows:
* Presence of a Clinical Emergency:
If the screening examination leads to a clinical determination by the examining physician that an actual emergency medical condition exists, the Managed Care Plan must pay for both the services involved in the screening examination and the services required to stabilize the patient.

* Emergency Services Continue Until the Patient Can be Safely Discharged or Transferred: The Managed Care Plan is required to pay for all emergency services which are Medically necessary until the clinical emergency is stabilized. This includes all treatment that may be necessary to assure, within reasonable medical probability, that no material deterioration of the patient's condition is likely to result from, or occur during, discharge of the patient or transfer of the patient to another facility. If there is a disagreement between a hospital and the Managed Care Plan concerning whether the patient is stable enough for discharge or transfer, or whether the medical benefits of an unstabilized transfer outweigh the risks, the judgment of the attending physician(s) actually caring for the enrollee at the treating facility prevails and is binding on the Managed Care Plan...

* Absence of a Clinical Emergency: If the screening examination leads to a clinical determination by the examining physician that an actual emergency medical condition does not exist, then the determining factor for payment liability should be whether the enrollee had acute symptoms of sufficient severity at the time of presentation...

* Referrals: When an enrollee's primary care physician or other plan representative instructs the beneficiary to seek emergency care in-network or out-of-network, the plan is responsible for payment for the medical screening examination and for other medically necessary emergency services, without regard to whether the patient meets the prudent layperson standard described above." West Virginia Contract, pages 11-12.

"The MCP must offer FQHCs and RHCs terms and conditions, including reimbursement, that are at least equal to those offered to other providers of comparable services. DHHR will reconcile reasonable costs with FQHCs and RHCs if the centers have. not negotiated alternative payments with the MCP (i.e., centers can waive their rights to reasonable cost reimbursement by taking capitation)." West Virginia RFA, page 22.

"Appendix C
Family Planning Services Fee Schedule
This is a fee schedule for family planning services provided by practitioners (including physician, midwives, certified nurse practitioners) or clinics...
This fee schedule is not all inclusive.

ABBREVIATED DESCRIPTION/ CURRENT REIMBURSEMENT
New patient office visit/ $21.11...
Established patient office visit/ $18.28...
Insertion, implantable contraceptive capsules/ $75.68…" West Virginia RFA, Appendix C, page C1.

"III. FUNCTIONS AND DUTIES OF THE HMO
In consideration of the functions and duties of the Department contained in this Contract the HMO shall: ...

B. PROVISION OF CONTRACT SERVICES...
9. The following provision refers to payments made by the HMO. HMO covered primary care and emergency care services provided to a recipient living in a Health Professional Shortage Area (HPSA) or by a provider practicing in a HPSA must be paid at an enhanced rate of 20% above the rate the HMO would otherwise pay for those services… Specified HMO-covered obstetric or gynecological services (see Part K of the Wisconsin Medicaid Provider Handbook) provided to a recipient living in a HPSA or by a provider practicing in a HPSA must be paid at an enhanced rate of 25% above the rate the HMO would otherwise pay providers in HPSAs for those services.

However, this does not require the HMO to pay more than the Medicaid fee-for-service rate or the actual amount billed for these services. The HMO shall ensure that the moneys for HPSA payments are paid to the physicians and are not used to supplant funds that previously were used for payment to the physicians…" Wisconsin Contract, pages 5, 9-10.

"E. EMERGENCY CARE - Promptly provide or pay for needed contract services for emergency medical conditions as defined in Article 1.

1. Payments for qualifying emergencies (including services at hospitals or urgent care centers within the HMO service area(s)) are to be based on the medical signs and symptoms of the condition upon initial presentation. The retrospective findings of a medical work-up may legitimately be the basis for determining how much additional care may be authorized, but not for payment for dealing with the initial emergency. (Note: The Department will provide HMOs with a statewide list of urgent care centers.)

2. HMOs may require submission of a trip ticket with ambulance claims before paying the claim. Claims submitted without a trip ticket need only be paid at the service charge rate.

3. HMOs will pay a service fee for ambulance response to a call in order to determine whether an emergency exists, regardless of the HMO's determination to pay for the call.

4. HMOs will pay for emergency ambulance services based on established Medicaid criteria for claims payment of these services.

5. HMO will either pay or deny payment of a complete claim for ambulance services within 45 days of receipt of the claim.

6. HMOs will respond to appeals from ambulance companies within the time frame described in Article III. J. Failure will constitute HMO agreement to pay the appealed claim in full...

J. PAYMENTS FOR DIAGNOSIS OF WHETHER AN EMERGENCY CONDITION EXISTS - Pay for appropriate, medically necessary, and reasonable diagnostic tests utilized to determine if an emergency exists.

K. MEMORANDA OF UNDERSTANDING FOR EMERGENCY SERVICES - HMOs may have a contract or a MOU with hospitals or urgent care centers within the HMOs service area(s) to ensure prompt and appropriate payment for emergency services...

Unless a contract or MOU species otherwise, HMOs are liable to the extent that fee-for-service would have been liable for the emergency situation. The Department reserves the right to resolve disputes between HMOs, hospitals and urgent care centers regarding emergency situations based on fee-for-service criteria." Wisconsin Contract, pages 12-15.

"II. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CENTERS (FQHCs AND RHCs) - If an HMO contracts with a facility or program, which has been certified as an FQHC or RHC by the Medicaid Program, for the provision of services to its enrollees, the HMO must negotiate payment rates for that FQHC or RHC on the same basis as it negotiates with other clinics and primary providers and the HMO must increase the FQHC's or RHC's payment in direct proportion to the annual increase for physicians' services in the capitation rate paid to the HMO. In other words, if an HMO receives a 10% increase from the Department for physicians' services, the contracted rates paid to the FQHC or RHC either through capitation or fee-for-service, must be increased by at least 10% over those that were in effect on the date this Contract is signed. The Department will notify the HMOs of the percentage increase for physician services made in the capitation rates by the Department when such changes occur…" Wisconsin Contract, page 34.