Traditionally, Federally Qualified Health Centers (FQHCs) were reimbursed based on their costs. That changed in 2000, with passage of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA).
It put in place what is called the Prospective Payment System (PPS). It also allowed states to use an alternative payment methodology (APM), but only if the health centers agreed to it and only if the state payment method didn’t pay health centers less than what they would have gotten under the federal PPS.
- Powerpoint: The Medicaid FQHC Prospective Payment System (March 2010)
- Q & A’s on FQHC Prospective Payment System (2001)
Implementation of Medicaid PPS
The following publications provide information on trends and best practices related to Medicaid PPS implementation.
- Medicaid Prospective Payment System Checklist – Promising Practices #12
- Emerging Issues in the FQHC Prospective Payment System – State Policy Report #38
- 2015 Update on the Implementation of the FQHC PPS in the States – State Policy Report #57
- 2014 Update on Implementation of the FQHC PPS in the States – State Policy Report #52
Change in FQHC Scope
- Defining an Effective Change in Scope Process – Emerging Issues #6
- Change of Scope for Electronic Health Records – Promising Practices #7
- Medicaid Reimbursement for Multiple Same-Day Encounters: Florida’s Experience – Emerging Issues #7
- FQHC Reimbursement for Vision Services in Medicaid – State Policy Report #50
- FQHC Reimbursement for Telemedicine Services in Medicaid – State Policy Report #48
- Health Center Reimbursement for Behavioral Health Services in Medicaid – State Policy Report #34
- Securing Adequate Payments for Obstetrical Services – Promising Practices #3
- BPHC Program Information Notice 2004-05: Medicaid Reimbursement for Behavioral Health Services
Children’s Health Insurance Program (CHIP) and PPS
The following publications provide information on trends and best practices related to CHIP PPS implementation.
- Status of PPS Implementation in the Children’s Health Insurance Program – State Policy Report #42 (NACHC, 2012)
- Status of CHIP Prospective Payer System Implementation: An Assessment of State CHIP Directors (ASTHO, 2011)
- Issue Brief: Summary of CHIP FQHC PPS Reimbursement Guidance (NACHC, 2010)