PPS Payments to FQHCs under Contract with MA Plans

60.5 - PPS Payments to FQHCs under Contract with MA Plans (Rev. 13264, Issued:06-09-25; Effective: 06-02-25; Implementation: 06-02-25) For claims with the 0519-revenue code, the wraparound payment is based on the PPS rate without comparison to the provider’s charge. The rate is also NOT adjusted for coinsurance or preventive services as the MA plan would have already assessed any applicable coinsurance and related waivers of coinsurance. Medicare will compare the PPS rate with the MA contract rate for a FQHC visit. When the MA contract rate is lower than the applicable PPS rate that would otherwise have been paid by traditional Medicare had the beneficiary not been covered by the MA plan, the contractor will pay the difference as a supplemental wraparound payment. The FQHC does not qualify for a supplemental wraparound payment when the MA contract rate is higher than the applicable PPS rate that would otherwise have been paid by traditional Medicare had the beneficiary not be covered by the MA plan. Example: MA Claim that Qualifies for a Supplemental Wraparound Payment PPS Rate = $225 Appropriate Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge 0519 G0468 - FSPC 10/01 170.00 170.00 0519 G0439 - PS 10/01 150.00 150.00 0001 320.00 320.00 If the MA contract rate is lower than the applicable PPS rate – e.g., $200: Wraparound payment = PPS rate – MA contract rate = $225 - $200 = $25 Note that the charge of $170 would reflect the FQHCs typical charge for G0468 but would not be used to calculate the supplemental payment. Example: MA Claim that Does Not Qualify for a Supplemental Wraparound Payment PPS Rate = $225 Appropriate Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge 0519 G0468 - FSPC 10/01 170.00 170.00 0519 G0439 - PS 10/01 150.00 150.00 0001 320.00 320.00 If the MA contract rate was higher than the applicable PPS rate – e.g., the MA contract rate was $250- no wraparound payment is due to the FQHC.