FQHC and RHC Alternative Payment Methodology for COVID-19 Vaccines

Collection of required agreements from facilities to participate in alternative payment methodology

This survey is to collect agreement from all facilities that want to participate in an alternative payment methodology for COVID-19 vaccine FQHC or RHC reimbursement.

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* 1. Provider Type:

FQHC

RHC

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* 2. Facility Information

National Provider Identifier (NPI 10 digits)

Medicare Provider Number or CMS Certification Number (CCN). Please input WAIVER if the facility has a Medicare waiver.

Provider Name

Doing Business As (If Different than Provider Name)

County

ZIP

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* 3. Tax Identification Number (TIN/EIN, not to be confused with Texas Identification Number) (9 digits)

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* 4. Please enter any additional (e.g., satellite) NPIs associated with this TIN (if applicable). Please use a comma (",") to separate each unique NPI.

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* 5. Contact Information

Name

Title

Email Address

Phone Number

Beginning December 11, 2020, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can be reimbursed for COVID-19 vaccine administration services.

This additional reimbursement is available as an alternative payment methodology (APM) based on an emergency State Plan Amendment approved by CMS for the COVID-19 vaccine administration. This APM allows for the COVID-19 vaccine administration to be reimbursed outside of the prospective payment system (PPS) encounter rate when that is the only service provided on that date. This APM was developed to support FQHCs and RHCs, as key COVID-19 vaccine providers identified in Texas’ COVID-19 Vaccination Plan. Payments under this APM are to cover the costs associated with the administration of COVID-19 vaccines by FQHCs and RHCs during the COVID-19 vaccine-only visits during the public health emergency (PHE). If the FQHC or RHC bills the vaccine as part of a medical visit, the FQHC or RHC would be paid the PPS rate only. The amount paid under this APM is the Medicaid Fee Schedule rate for the administration of COVID-19 vaccines, which is equivalent to the Medicare rate developed by CMS to account for the additional costs associated with the administration of COVID-19 vaccines. FQHCs or RHCs that opt-in to this APM agree that the Medicaid Fee Schedule rate covers their costs associated with the administration of the COVID-19 vaccines for COVID-19 vaccine only visit. This rate is being used for COVID-19 vaccine -only visits as cost data history is not available for the rate development.

In the event that a FQHC or RHC fails to complete this survey or does not agree to this alternative payment methodology (APM) as explained above, HHSC may recoup up to all payments for vaccine-only visits. Encounter rate qualified visits may be unaffected.

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* 6. I have read the alternative payment methodology (APM) for COVID-19 vaccine reimbursement for FQHC and RHCs.

Yes

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* 7. I agree to the APM for COVID-19 Vaccines for the facility identified in Question 1.

I agree

By submitting this survey, the facility attests that the individual identified in Question 3 is authorized to sign this document on behalf of the facility, and the signatory affirms that the information provided is accurate.