CMS Pub. 100-16, ch. 8, § 110

Per 42 CFR 422.316, FQHCs will receive a “wrap-around payment” from CMS

representing the difference (if any) between what they are paid by an MA organization,

including beneficiary cost sharing, and 100 percent of their “reasonable costs” of providing

care to patients served at the centers who are enrolled in an MA plan at a minimum on a

quarterly basis. The FQHC must have a written agreement with the MA organization

offering the plan concerning the provision of this service (including the agreement required

under §1857(e)(3) of the Act and as codified in 42 CFR 422.527).

The MA organizations that contract with FQHCs must pay the FQHCs an amount that is

not less than the level and amount of payment they would make for the services if

furnished by an entity providing similar services that was not an FQHC. This is designed

to avoid an agreement between an MA organization and an FQHC for payment of an

artificially low rate, with the knowledge that the FQHC would receive supplemental

payments from us resulting in a total of 100 percent cost reimbursement.

The PFFS plans that have "deemed" networks must pay what the FFS Medicare program

pays to the "provider in question," per 42 CFR 422.114(a)(2)(i). Therefore, there would be

no wrap-around payment for FQHCs treating PFFS patients under a "deemed" contract

because the FQHC would be receiving full payment from the plan.