A.Reimbursement for Tribal Health Clinics
1. Services provided by or through facilities of the Indian Health Services (IHS) which includes, at the option of the tribe, facilities operated by a tribe or tribal organization and funded by Title I or V of the Indian Self Determination and Education Assistance Act, also known as Tribal 638 facilities, are paid at the applicable IHS OMB rate published in the annual Federal Register or Federal Register Notices by IHS.
2. The most current published IHS OMB outpatient per visit rate, also known as the outpatient all-inclusive rate, is paid for up to five (5) outpatient visits per beneficiary per calendar day for professional services. An outpatient visit is defined as a face-to-face or telemedicine contact between any health care professional, at or through the IHS facility as described above, authorized to provide services under the State Plan and a beneficiary for the provision of Title XIX defined services, as documented in the beneficiary’s medical record.
3. To be included in the outpatient per visit rate are Medicaid-covered pharmaceutical/drugs, dental services, rehabilitative services, behavioral health services, any and all ancillary services, and emergency room services provided on-site and medical supplies incidental to the services provided to the beneficiary.
B. Virginia Medicaid reimburses Tribal 638 facilities in accordance with the most recently published annual update of reimbursement rates for Indian Health Services, which is published in the Federal Register and on the Indian Health Services website (https://www.ihs.gov) on the page for reimbursement rates. Encounters/visits are limited to healthcare professionals as approved under the Virginia Medicaid State Plan. A tribal health program selecting to enroll as a FQHC and agreeing to an alternate payment methodology (APM) will be paid using the APM.
C. Alternative Payment Methodology for Tribal Facilities Recognized as FQHCs
1. Outpatient health programs or facilities operated by a Tribe or Tribal organization that choose to be recognized as FQHCs in accordance with Section 1905 (I)(2)(B) of the Social Security Act and the Indian Self-Determination Act (Public Law 93-638) will be paid using an alternative payment methodology (APM) for services, that is the published, all-inclusive rate (AIR). The APM/AIR rate is paid for up to five face-to-face encounters/visits per recipient per day.
2. The individual FQHC must agree to receive the APM. If a Tribal FQHC does not agree to accept the APM, DMAS shall seek accommodation with the FQHC, which may include submitting a state plan amendment to authorize an alternative means of reimbursement for the FQHC.