Federally qualified health center or rural health clinic visit
HRS §346-53.64
in effect346-53.64. Federally qualified health center or rural health clinic visit
(a) Services eligible for prospective payment system reimbursement are those services that are furnished by a federally qualified health center or rural health clinic that are:
(1) Within the legal authority of a federally
qualified health center to deliver, as defined in section 1905 of the Social
Security Act;
(2) Actually provided by the federally qualified
health center, either directly or under arrangements;
(3) Covered benefits under the medicaid program, as
defined in section 4231 of the State Medicaid Manual and the Hawaii medicaid
state plan;
(4) Provided to a recipient eligible for medicaid benefits;
(5) Delivered exclusively by health care professionals,
including physicians, physician's assistants, nurse practitioners, nurse
midwives, clinical social workers, clinical psychologists, and other persons
acting within the lawful scope of their license or certificate to provide
services;
(6) Provided at the federally qualified health
center's practice site, a hospital emergency room, in an inpatient setting, at
the patient's place of residence, including long term care facilities, or at
another medical facility; and
(7) Within the scope of services provided by the State
under its fee-for-service medicaid program and its medicaid managed care
program, on and after August 1994, and as amended from time to time.
(b) Contacts with one or more health
professionals and multiple contacts with the same health professional that take
place on the same day and at a single location constitute a single encounter,
except when one of the following conditions exists:
(1) After the first encounter, the patient suffers
illness or injury requiring additional diagnosis or treatment; or
(2) The patient makes one or more visits for other
services such as dental or behavioral health. Medicaid may pay for a maximum
of one visit per day for each of these services in addition to one medical
visit.
(c) A federally qualified health center or rural
health clinic that provides prenatal services, delivery services, and postnatal
services may elect to bill the managed care organization for all such services
on a global payment basis. Alternatively, it may bill for prenatal and
postnatal services separately from delivery services and be paid the per visit
prospective payment system reimbursement for prenatal and postnatal visits. In
this case, it may bill the managed care organization separately for inpatient
delivery services that are not eligible for prospective payment system
reimbursement. [L Sp 2008, c 8, pt of §2; am L 2015, c 20, §4]
Note
Section effective upon approval of the Hawaii medicaid state
plan by the Centers for Medicare and Medicaid Services. L Sp 2008, c 8, §9.
L Sp 2008, c 8, §5 provides:
"SECTION 5. The department of health may provide
resources to nonprofit, community-based health care providers for direct
medical care for the uninsured, including:
(1) Primary
medical;
(2) Dental;
(3) Behavioral
health care; and
(4) Ancillary
services, including:
(A) Education;
(B) Follow-up;
(C) Outreach;
and
(D) Pharmacy
services.
Distribution of funds may be on a "per-visit" basis,
taking into consideration need on all islands."
Source: Hawaii State Legislature (capitol.hawaii.gov), via Internet Archive capturesURL: http://www.capitol.hawaii.gov/hrscurrent/Vol07_Ch0346-0398/HRS0346/HRS_0346-0053_0064.htmFetched: 11/10/2026