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FQHC/RHC Prospective Payment System Plus Reimbursement Methodology Project - Review and Research Report

Download this publicationOver the past several years, the Department of Health Care Policy and Financing (the Department) has laid the foundation for increasing its ability to link health care expenditures with health outcomes and value. The Department is interested in using the opportunity presented by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) requirements related to Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) reimbursement to further this strategic goal. CHIPRA requires state Children’s Health Insurance Programs to adopt a prospective payment system for FQHCs/RHCs. The Department received a grant from the Centers for Medicare and Medicaid Services (CMS) to assist with implementing the PPS requirement in Colorado’s CHIP program (called CHP+) and has engaged JSI to assist with the process.

The Department intends to develop a rate methodology for FQHCs and RHCs tentatively referred to as PPS Plus, which will go beyond the current prospective payment system used in Medicaid to provide quality/outcome incentives in the state CHP+ and Medicaid programs.

In order to inform the state’s approach to CHIPRA PPS implementation, JSI conducted research on CHIPRA PPS implementation, value-based purchasing, and Colorado’s current programs and systems. The research included a review of pertinent reports and articles; research into Colorado’s payment methodologies, quality initiatives, and value-based strategies; input from key stakeholders including FQHCs, RHCS, their state associations and Medicaid/CHP+ managed care organizations (MCOs); and key informant interviews with national experts and state Medicaid/CHIP programs to identify pertinent national trends and understand the experience of other states with PPS implementation in CHIP and value-based purchasing strategies and methodologies. This report presents the research findings. JSI Research & Training Institute, Inc. 2012

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