Health Center Regulatory Issues, Uncategorized

Exchange Requirements on Contracting and Payment to FQHCs

We’ve been hearing from a lot of you with questions on the Exchange and the contracting and payment requirements for Qualified Health Plans and FQHCs. We’ve put together this Q&A in hopes that it helps answer your questions and provides you with some additional helpful resources. Please don’t hesitate to contact Roger or Susan with any other questions you might have and be sure to check back for more Q&As as we get more questions from you.

Is there a requirement that Qualified Health Plans must contract with FQHCs?  How will QHPs pay FQHCs?

The Affordable Care Act does not include a requirement that Qualified Health Plans (QHP) contract with FQHCs.  The law does include a requirement that QHPs contract with “essential community providers” and assure reasonable access to these providers.[1]  The definition of ECPs includes those covered entities under the 340B drug discount program, which includes FQHCs.[2]  While the law says that QHPs must contract with ECPs, it does not say that a QHP must contract will all ECPs.  NACHC tried to make the case to CMS that the ACA provided the federal agency enough leeway to require QHPs to contract with “any willing FQHC”, which we argued would insure that the QHP complied with the provider and ECP reasonable access requirements of the ACA.  However, CMS did not adopt this position in its final rule.  A review of what the Exchange rules require with regard to FQHCs can be found in this NACHC Issue Brief (see pages 4-9).  

In regards to payment, the ACA specifies that a QHP must pay an FQHC no less than it would be paid under Medicaid unless the plan and the FQHC agree on a different payment amount (which could not be less than the generally applicable payment rates of the QHP issuer).[3]  While this is clear when an FQHC contracts with a QHP, we did not feel the regulation was clear when an FQHC is not contracted with an FQHC.  In order to clarify, NACHC sent a letter to the Center for Consumer Information and Insurance Oversight (CCIIO), requesting clarification on what the requirements are when a QHP has not contracted with an FQHC, but an enrollee of the QHP has sought and received care at the FQHC.  CCIIO responded that in such circumstances the QHP must pay the FQHC based on Medicaid PPS payment, meaning that while a QHP need not contract with an FQHC, it would have to pay the FQHC based on PPS when the QHP enrollee has gone out-of-plan to the FQHC.  We hope this policy will encourage QHPs to contract with FQHCs.


[1] 45 CFR 156.235
[2] 45 CFR 156.235(c)
[3] 45 CFR 156.235 (e)