Tips for Seeking a State-Directed Payment

Tips for Seeking a State-Directed Payment

• Behavioral health services appear under many benefit categories. PCAs should clarify with the state which services are included in any existing or proposed state-directed payment arrangement. PCAs should work directly with their state Medicaid agency to define the parameters for provider payments of a particular service.
• It should not be assumed that FQHCs are included as a qualified provider eligible to receive a state-directed payment. PCAs should ensure any supplemental payment includes the behavioral health services provided by an FQHC, and state Medicaid agencies should explicitly identify FQHCs as eligible providers and recipients of those payments. In other words, the State is acknowledging that these state-directed supplemental payments are for FQHC services.
• It is important to seek clarification on whether supplemental payments must be reconciled to encounters prior to agreeing to any such payment arrangement. Keep in mind that the state Medicaid agency must agree that these state-directed supplemental payments from the MCOs to FQHCs are not to be included as State or MCO payments for purposes of FQHC wrap-around. That is, they are to be in addition to whatever wrap-around payment the FQHC is due from the State or the MCO per the PPS wrap-around requirements of 1902(bb)(5) or an APM per 1902(bb)(6).

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