By: Susan Sumrell

On June 8, the Center for Consumer Information and Insurance Oversight (CCIIO), the agency responsible for the creation and approval of Exchanges, responded to a letter from NACHC sent earlier this year seeking clarification on the final rule (published on March 27, 2012) on Exchanges. Specifically, we were looking for clarification that a Qualified Health Plan (QHP) must be required to pay an FQHC its Medicaid PPS rate (or APM) for the items and services the FQHC provides to a QHP enrollee, regardless of whether the FQHC is contracted with the QHP to provide items and services to its enrollees. CCIIO agreed with our interpretation of the final rule, stating in the letter that “[w]e believe that, consistent with §§ 1302(g), 1311(c)(1)(C), and 1311(c)(2) of the Affordable Care Act, § 156.235(e) and the preamble are sufficiently clear in expressing that a QHP issuer must pay an FQHC the relevant FQHC Medicaid PPS rate for the items and services that the FQHC provides to a QHP enrollee, if the QHP issuer and the FQHC have not contracted on a mutually agreed upon rate that is at least equal to the QHP issuer’s general applicable payment rate. This would generally mean that if a QHP issuer does not have a contract with an FQHC, the QHP issuer must pay the FQHC the Medicaid PPS rate for the items and services provided to a QHP enrollee.”

We continue to work with Senator Menendez‘s office to ensure that this is clarified in regulation, which he expressed to us at the Policy and Issues forum in March. In the interim, this response from CCIIO is great progress on such an important issue and we encourage you to review the letter and use it in your discussions with your state and QHPs about FQHC involvement in the Exchanges.