US · guidance
CMS Pub. 100-02, ch. 13, § 220.4
Copayment for FQHC Preventive Health Services
Under the FQHC PPS, coinsurance will generally be 20 percent of the lesser of the
FQHC’s charge or the PPS rate. When one or more qualified preventive services are
provided as part of an FQHC visit, the A/B MAC will use the lesser of the FQHC’s
charge for the specific FQHC payment code or the PPS rate to determine the total
payment amount. To determine the amount of Medicare payment and the amount of
coinsurance that should be waived, the A/B MAC will use the FQHC’s reported line-item charges and subtract the dollar value of the FQHC's reported line-item charge for the
preventive services from the full payment amount.
For FQHC claims that consist solely of preventive services that are exempt from
beneficiary coinsurance, Medicare pays 100 percent of the lesser of the FQHC’s charge
or the FQHC PPS rate, and no beneficiary coinsurance is assessed.
History
(Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
e013dd9901c88161b0addc4b492ac5a020b7cf804e647f6a4ee3adb5e1fc527e
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