Reimbursement : Amounts

All-Inclusive Rate Reimbursement

Wisconsin Tribal FQHCs receive reimbursement for Medicaid-covered services through one of two options:

• PPS—ForwardHealth establishes a prospective encounter rate for each Tribal FQHC that reflects their estimated reasonable costs of providing care in accordance with the Benefits Improvement and Protection Act of 2000.
• AIR—IHS calculates and publishes all-inclusive reimbursement rates each year in the Federal Register. The rates are based on annual cost reports prepared by IHS's contractor.

ForwardHealth uses these reimbursement rates through the authority of the approved Wisconsin State Plan Amendment 24-0008. The Medicaid State Plan Attachment 4.19-B has:

• Pharmacy information on page 5a.
• AIR information on pages 10.d.–10.h.

ForwardHealth does not reimburse Tribal FQHCs under the cost-settlement process for services rendered on and after January 1, 2024.

Rates and Reimbursement

Under AIR, ForwardHealth reimburses Tribal FQHCs for an encounter rate which includes all direct and indirect services provided to a member during an encounter.

ForwardHealth will apply the PPS rate or AIR for the encounter type to a claim detail associated with HCPCS procedure code T1015. All other payable claim details for direct and indirect services on the claim associated with the encounter will process in a paid status with a $0 allowed amount.

ForwardHealth only reimburses Tribal FQHCs for covered services and does not reimburse providers for the cost of any Tribal FQHC activities and services that:

• Are not required by ForwardHealth.
• Are part of Tribal FQHC-related services included in state statute or administrative code.

Calculation of the All-Inclusive Rate

A Tribal FQHC's AIR will be reimbursed per the rate published annually in the Federal Register.

Choosing a Reimbursement Rate

The Tribal FQHC can choose between the PPS or AIR as their preferred reimbursement rate at the start of each calendar year using this information:

1. CMS will publish the market basket data and update the Federal Register for the upcoming year.
2. Wisconsin DHS will send a letter to the Tribal FQHC detailing the new rates for both PPS and AIR. DHS intends for Tribal FQHCs to receive these letters in December each year.
3. Tribal FQHCs must inform DHS of their chosen rate for the upcoming year within the timeline specified in the letter.

If a Tribal FQHC chooses their rate after January 1, non-pharmacy claims dating back to January 1 will be automatically adjusted to their chosen rate.

If the Tribal FQHC does not send a decision to DHS within the timeline detailed in the letter, DHS will apply the method the Tribal FQHC chose the previous year with the updated rates.

Billing Procedure Code

The Tribal FQHC PPS or AIR implementation date is the date when a Tribal FQHC became eligible for billing HCPCS procedure code T1015 (Clinic visit/encounter, all inclusive) for eligible claims. Billing providers must include HCPCS code T1015 on the claim along with a dental, mental health, or medical covered service code to receive their PPS rate or AIR for qualified encounters.

Tribal FQHCs may email the Wisconsin DHS Tribal FQHC inbox at DHSTRIBALFQHC@dhs.wisconsin.gov to find out when they can start submitting claims with HCPCS code T1015.