Medicaid patients comprise about 40% of health center patients and Medicaid payments comprise about 38% of all health center revenues. This Manual covers a myriad of topics related to the Medicaid FQHC Prospective Payment System (PPS), which is the payment methodology that federal law requires states to use in reimbursing federally qualified health centers. Topics discussed in this document include, among others: sources of Medicaid federal and state law relating to health center reimbursement, definitions of FQHC services, the history of FQHC PPS and establishment of FQHC PPS rates, payments to health centers in Medicaid managed care programs including FQHC "wraparound" issues, FQHC services and payment issues in Section 1115 waiver programs, and strategies relating to payment to health centers as states focus on Medicaid payment reforms.
This document reviews numerous topic relating to Medicaid PPS Reimbursement to Federally qualified health centers.It will serve as a useful resource for staff at health centers and state primary care associations, and for anyone involved in health care policy who is interested in understanding Medicaid payment issues affecting health centers.
Important MyNACHC Content Note: This technical assistance resource was developed prior to the August 2017 release of the Health Center Compliance Manual by the Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care (BPHC). The BPHC Compliance Manual, issued August 2017, indicates where PINS, PALs and other program guidance are now superseded or subsumed by the BPHC Compliance Manual. See https://bphc.hrsa.gov/programrequirements/pdf/healthcentercompliancemanual.pdf