MEDICAID – Adds to existing law to provide legislative approval for the Department of Health and Welfare to submit a state plan amendment regarding change in encounter rate due to change in scope of services.

LEGISLATURE
OF
THE
STATE
OF
IDAHO
Sixty-eighth
Legislature
Second
Regular
Session
-
2026
IN
THE
SENATE
SENATE
BILL
NO.
1410
BY
STATE
AFFAIRS
COMMITTEE
AN
ACT
1
RELATING
TO
MEDICAID;
AMENDING
CHAPTER
22,
TITLE
56,
IDAHO
CODE,
BY
THE
AD
-
2
DITION
OF
A
NEW
SECTION
56
-
2208,
IDAHO
CODE,
TO
PROVIDE
LEGISLATIVE
AP
-
3
PROVAL
FOR
STATE
PLAN
AMENDMENTS
REGARDING
CHANGE
IN
ENCOUNTER
RATE
DUE
4
TO
CHANGE
IN
SCOPE
OF
SERVICES;
PROVIDING
THAT
CERTAIN
ADMINISTRATIVE
5
RULES
CONTAINED
IN
IDAPA
16.03.26
SHALL
BE
NULL,
VOID,
AND
OF
NO
FORCE
6
AND
EFFECT
AND
PROVIDING
APPLICABILITY;
AND
DECLARING
AN
EMERGENCY.
7
Be
It
Enacted
by
the
Legislature
of
the
State
of
Idaho:
8
SECTION
1.
That
Chapter
22,
Title
56,
Idaho
Code,
be,
and
the
same
is
9
hereby
amended
by
the
addition
thereto
of
a
NEW
SECTION
,
to
be
known
and
des
-
10
ignated
as
Section
56
-
2208,
Idaho
Code,
and
to
read
as
follows:
1
1
56
-
2208.
LEGISLATIVE
APPROVAL
-
-
CHANGE
IN
ENCOUNTER
RATE
DUE
TO
12
CHANGE
IN
SCOPE
OF
SERVICES.
(1)
The
department
of
health
and
welfare
is
au
-
13
thorized
to
and
shall
submit
the
state
plan
amendments
required
to
carry
out
14
the
provisions
of
this
section
no
later
than
October
1,
2026.
15
(2)(a)
As
required
by
42
U.S.C.
1396a(bb)(3)(B),
the
department
shall
16
adjust
the
prospective
payment
system
(PPS)
encounter
rates
of
feder
-
17
ally
qualified
health
centers
(FQHCs)
and
rural
health
clinics
(RHCs)
18
based
on
any
change
in
scope
of
FQHC
or
RHC
services,
as
defined
by
42
19
U.S.C.
1396d(a)(2)(B)
and
(C).
20
(b)
A
change
in
scope
of
services
is
one
that
affects
the
type,
in
-
21
tensity,
duration,
or
number
of
services
provided
by
a
FQHC
or
RHC.
A
22
change
in
the
scope
of
FQHC
or
RHC
services
may
occur
if
the
FQHC
or
RHC
23
has
added,
dropped,
or
expanded
any
service
that
meets
the
definition
24
of
a
FQHC
or
RHC
service
pursuant
to
42
U.S.C.
1396d(a)(2)(B)
and
(C).
25
A
change
in
the
cost
of
a
service
is
not
considered
in
and
of
itself
a
26
change
in
the
scope
of
services.
27
(c)
To
qualify
for
a
rate
adjustment,
applications
for
a
rate
review
28
must
meet
a
minimum
four
and
one
-
half
percent
(4.5%)
cumulative/aggre
-
29
gate
change
in
cost
per
medical
or
dental
visit
as
measured
by
comparing
30
the
cost
per
encounter
with
change
in
scope
of
services
to
the
then
cur
-
31
rent
PPS
rate.
32
(3)
All
reasonable
efforts
shall
be
made
to
submit
written
notifica
-
33
tion
of
a
planned
change
in
scope
to
the
department
sixty
(60)
days
prior
to
34
implementation
of
a
change
in
scope.
Notification
shall
provide
a
detailed
35
description
of
the
planned
change
in
scope.
The
department
shall
not
impose
36
penalties
related
to
this
section.
37
(4)
Applications
for
a
rate
adjustment
shall
be
filed
with
the
depart
-
38
ment
once
the
change
in
scope
of
service
has
been
fully
implemented
for
a
pe
-
39
riod
of
six
(6)
consecutive
months.
Full
implementation
means
costs
were
in
-
40
curred
and
services
were
provided
without
interruption
for
a
consecutive
six
41
(6)
month
period.
Requests
for
the
determination
of
a
change
in
scope
and
a
42

2
PPS
rate
review
must
be
received
by
the
last
day
of
the
third
month
follow
-
1
ing
the
end
of
the
consecutive
six
(6)
month
period
after
the
change
in
scope.
2
FQHCs
and
RHCs
may
submit
a
maximum
of
one
(1)
application
for
a
rate
adjust
-
3
ment
based
on
a
change
in
scope
of
services
per
fiscal
year.
Applications
for
4
a
rate
adjustment
shall
include:
5
(a)
A
written
narrative
describing
the
specific
changes
in
scope
of
6
services
and
how
these
changes
relate
to
a
change
in
the
FQHC's
or
RHC's
7
overall
scope
of
services;
8
(b)
A
full
cost
report
including
all
cost
and
encounter
information
for
9
the
first
six
(6)
consecutive
months
of
operations
after
the
change
in
10
scope
was
implemented;
and
1
1
(c)
Any
additional
supplemental
data
requested
by
the
department
that
12
is
reasonably
necessary
to
support
the
department's
evaluation
of
the
13
application.
14
(5)(a)
The
department
shall
review
and
accept,
reject,
or
adjust
a
re
-
15
quest
for
a
rate
adjustment
within
ninety
(90)
days
of
receiving
an
ap
-
16
plication.
17
(b)
If
further
documentation
or
records
are
requested
by
the
depart
-
18
ment
after
receiving
a
request
for
rate
adjustment,
the
applicant
shall
19
have
up
to
two
(2)
weeks
to
respond
to
the
request.
The
period
of
days
20
beginning
with
the
request
for
further
documentation
or
records
by
the
21
department
and
ending
with
the
response
from
the
applicant
shall
not
be
22
counted
toward
the
ninety
(90)
day
requirement
described
in
paragraph
23
(a)
of
this
subsection.
24
(c)
After
reviewing
and
accepting,
rejecting,
or
adjusting
a
request
25
for
rate
adjustment,
the
department
shall
provide
a
draft
calculation
26
for
the
final
rate
to
the
applicant
for
a
change
in
scope
of
services.
27
The
applicant
shall
have
a
review
period
of
sixty
(60)
days
to
review
and
28
respond
to
such
draft
calculation.
29
(d)
The
final
rate
calculation
shall
be
issued
within
forty
-
five
(45)
30
days
after
the
review
period
described
in
paragraph
(c)
of
this
subsec
-
31
tion.
32
(e)
The
department's
final
PPS
encounter
rate
may
be
appealed
by
the
ap
-
33
plicant
within
thirty
(30)
days
of
the
department's
final
decision.
34
(f)
The
final
PPS
encounter
rate
shall
be
effective
the
first
day
of
the
35
implementation
of
the
change
in
scope.
The
department
shall
reconcile
36
encounter
payments
for
cost
differences
from
the
first
day
of
implemen
-
37
tation
of
the
new
PPS
rate
to
completion
date,
to
include
any
encounters
38
not
reconciled
by
a
contracted
managed
care
entity.
39
SECTION
2.
The
rules
contained
in
IDAPA
16.03.26,
Department
of
Health
40
and
Welfare,
relating
to
Medicaid
Plan
Benefits,
Section
307.,
Subsection
41
03.,
shall
be
null,
void,
and
of
no
force
and
effect
on
and
after
October
1,
42
2026.
FQHCs
and
RHCs
that
began
a
change
in
scope
before
October
1,
2026,
43
may
complete
the
process
as
it
existed
under
department
rule
at
the
time
the
44
change
in
scope
began.
45
SECTION
3.
An
emergency
existing
therefor,
which
emergency
is
hereby
46
declared
to
exist,
this
act
shall
be
in
full
force
and
effect
on
and
after
its
47
passage
and
approval.
48