Total Medicare Paid (Apr)

$695,241

Total PPS Rate (Apr)

$1,519,125

Total Wrap-Around (Apr)

$823,884

Rule 1 All-Inclusive Rate — No Unbundling

The PPS rate is all-inclusive. FQHCs may not separately bill for services that are part of the qualifying visit (labs, X-rays, ancillaries performed same day by FQHC staff).

Rule 2 One PPS Encounter Per Day Per Discipline

Only one medical, one dental, and one mental health PPS encounter may be billed per beneficiary per day unless the patient presents with a separate and distinct medical condition.

Rule 3 Virtual Encounters (Telehealth)

Beginning Jan 1, 2024, FQHCs may bill PPS rate for telehealth encounters using place of service code 02. Originating site fee applies for Medicare. Audio-only permitted for mental health.

Rule 4 Preventive Services Exception

Preventive services under the USPSTF A/B ratings may be billed without cost-sharing. Apply modifier "33" to indicate preventive service. FQHC still collects PPS rate from payer.

Rule 5 Sliding Fee Scale — Patient Cost Sharing

Patient cost-sharing is based on sliding fee scale, not the PPS rate. The FQHC receives the full PPS rate from Medicaid/Medicare regardless of how much the patient pays out-of-pocket.