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* What health center do you represent?

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* YTD Financials

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* 2019 Cost per Visit

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* Current PPS Rate

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* 2019 Total Encounters

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* 2019 # Medicaid Encounters

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* Addition or deletion of new type of service: Check 1 for what needs to be included as a trigger for a CiS methodology (i.e., financial impact would be substantial); 2 for what would be nice to include as a trigger (i.e., would make a difference, but not absolutely necessary); and 3 for items that would not make much of a difference (i.e., either no difference if the clinic does not provide the service or costs for the service have not increased much based on when your existing PPS rate was established).

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Medical
Dental
Mental Health
Substance Use Disorder
OB/GYN
Pharmacy
Lab
X-ray
Optometry
Chronic pain management
MAT
Case management/care coordination for non-billable work
Social Determinants of Health (SDoH) interventions
Enabling services
Non-billable team member interactions
Chiropractic Care
Physical Therapy

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* Intensity, duration and amount of service: Check 1 for what needs to be included as a trigger for a CiS methodology (i.e., financial impact would be substantial); 2 for what would be nice to include as a trigger (i.e., would make a difference, but not absolutely necessary); and 3 for items that would not make much of a difference (i.e., either no difference if the clinic does not provide the service or costs for the service have not increased much based on when your existing PPS rate was established).

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Population (e.g., homeless, HIV/AIDS, other chronic diseases, elderly)
Services provided (e.g., those listed in addition/deletion of new type of service)
Regulatory compliance
HRSA approved scope of project
Technology (e.g., EMR, telemedicine)
Provider mix (e.g., internists)

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* Other: Check 1 for what needs to be included as a trigger for a CiS methodology (i.e., financial impact would be substantial); 2 for what would be nice to include as a trigger (i.e., would make a difference, but not absolutely necessary); and 3 for items that would not make much of a difference (i.e., either no difference if the clinic does not provide the service or costs for the service have not increased much based on when your existing PPS rate was established).

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SDoH Services
Changing capital costs from a remodel, relocation or establishing a new site
Technology (e.g., EMR, telemedicine)
Costs associated with a teaching health center

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* As we consider PPS rate adjustments, triggering events, thresholds and timing for adjustments, required versus voluntary adjustments, etc.--what are your primary concerns?

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* What do you hope to accomplish through the CiS discussions?

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