ModifiedAgency for Health Care AdministrationPolicy 2025-0015

Florida Title XIX Federally Qualified Health Center and Rural Health Clinic Reimbursement Plan

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Governs Medicaid reimbursement methodologies, encounter rates, supplemental payments, audits, payment assurance, and provider participation requirements for Florida FQHCs and RHCs, including providers contracting with Medicaid managed care plans.

Policy Summary

PayerAgency for Health Care Administration

PolicyFlorida Title XIX Federally Qualified Health Center and Rural Health Clinic Reimbursement Plan

Policy CodePolicy 2025-0015

Change TypeModified

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionSubmit FQHC supplemental payment requests quarterly within 30 days after the reported quarter and RHC requests monthly within 15 days after the reported month.

SourceLink

POLICY UPDATE CHANGES

For the October 2025 rate setting, an additional fixed amount of $6.18 is applied to each facility's established base PPS rate under the Alternative Payment Methodology.

The plan identifies quarterly FQHC and monthly RHC submission schedules for supplemental payment requests.

$6.18Fixed additional APM amount

10 yearsAudit report retention

75 days

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ModifiedAgency for Health Care AdministrationPolicy 2025-0015

Florida Title XIX Federally Qualified Health Center and Rural Health Clinic Reimbursement Plan

Customize your policy alerts

Sign up for Agency for Health Care Administration Policy 2025-0015 alerts

Get alerted when Policy 2025-0015 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerAgency for Health Care Administration

PolicyFlorida Title XIX Federally Qualified Health Center and Rural Health Clinic Reimbursement Plan

Policy CodePolicy 2025-0015

Change TypeModified

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionSubmit FQHC supplemental payment requests quarterly within 30 days after the reported quarter and RHC requests monthly within 15 days after the reported month.

SourceLink

POLICY UPDATE CHANGES

For the October 2025 rate setting, an additional fixed amount of $6.18 is applied to each facility's established base PPS rate under the Alternative Payment Methodology.

The plan identifies quarterly FQHC and monthly RHC submission schedules for supplemental payment requests.

$6.18Fixed additional APM amount

10 yearsAudit report retention

75 days

Scope increase retroactive limit

6 monthsActual cost information minimum

30 / 15 daysSupplemental request deadlines

68 and 66Eligible provider types

Reimbursement Eligibility and Methodologies

General FQHC and RHC PPS reimbursement

Covered for Florida Medicaid FQHCs and RHCs that meet the applicable provider, service, licensing, and reimbursement requirements.

ALL of the following

Provider eligibility
- Provider meets the applicable federal definition of an FQHC or RHC.
- Provider satisfies AHCA health standards and applicable state licensing requirements.
Covered services and payment
- Claimed services fall within allowable FQHC/RHC services and costs under the plan.
- Provider accepts Medicaid reimbursement as payment in full for covered services billed to Medicaid and does not charge Medicaid recipients additional amounts.

Scope-of-service encounter rate adjustment

An encounter rate adjustment may be available when the provider demonstrates a qualifying scope-of-service change and submits the required financial and supporting documentation.

ALL of the following

Qualifying scope change
- A new service is added that was not previously provided by the FQHC or RHC.
- An existing service provided by the FQHC or RHC is eliminated.
Provider demonstrates the change in cost caused by the scope-of-service change.
Submitted financial data contains at least six months of actual cost information.

Alternative Payment Methodology

Additional reimbursement is available when the FQHC or RHC agrees to the statutory Alternative Payment Methodology and the applicable rate-setting and reconciliation requirements are met.

ALL of the following

FQHC or RHC agrees to the Alternative Payment Methodology in accordance with section 1902(bb)(6) of the Social Security Act.
Applicable rate-setting condition
- For the October 1, 2024 APM, a facility's PPS rate falls below the statewide average PPS rate and is increased to the statewide average rate.
- For the October 1, 2025 rate setting, a fixed additional amount of $6.18 is applied to the facility's established base PPS rate.$6.18 per established base PPS rate
Additional APM funding is subject to annual reconciliation during rate setting to ensure that the amount paid through the APM is at least equal to the PPS rate.

Medicaid managed care supplemental payments

Supplemental payments are available for eligible FQHCs and RHCs that contract with Medicaid managed care plans participating in Statewide Medicaid Managed Care.

ALL of the following

Eligible provider type
- Provider is an FQHC with provider type 68.
- Provider is an RHC with provider type 66.
Provider has a contract with a Medicaid managed care plan providing services under the Statewide Medicaid Managed Care program.
Claims were filed with the Medicaid managed care plan using provider type 68 or 66.
Supplemental payment is calculated as the difference, if any, between the managed care plan's payment and the amount to which the FQHC or RHC would be entitled under section 1902(bb) of the Social Security Act.

Provider Types and Key Payment Parameters

Covered Provider-Type CodesmixedCovered

68	FQHC provider type
66	RHC provider type
25	Physician provider type; not eligible for supplemental payments

October 2025 APM Fixed Additional Amount

Effective dateOctober 1, 2025

Additional amount$6.18 applied to each facility's established base PPS rate

ConditionThe facility must agree to the Alternative Payment Methodology under section 1902(bb)(6) of the Social Security Act; additional funding is subject to annual reconciliation.

RHC Scope-of-Service Change Threshold

Scope change thresholdGreater than 1 percent

Applies toRural health clinics requesting an encounter rate adjustment for an increase or decrease in scope of services

Required Provider Actions

Documentation Required

Report scope-of-service changes

FQHCs and RHCs are responsible for notifying the Division of Medicaid of any change in scope of services and providing proper documentation.

Documentation Required

Support scope-related rate adjustments

When requesting an encounter rate adjustment due to an increase or decrease in scope of services, submit documentation demonstrating the cost change and all required financial data and cost reports.

Financial data must contain at least six months of actual cost information.
For an FQHC scope increase, submit the provider’s fiscal year-end audit before approval.
For an RHC request, file the most recent audited Medicare cost report and a budgeted cost report containing the scope-related cost increase or decrease.
Submit all requested financial data within 12 months after the fiscal year end in which the costs were first affected.

Key Policy Definitions

Acceptable Budgeted Cost Report

DefinitionA completed, legible cost report containing all relevant schedules, worksheets, and supporting documents.

Required schedulesAll relevant schedules and worksheets must be included.

Required supportSupporting documents must be included with the cost report.

Encounter

Core definitionA face-to-face contact between a recipient and a health care professional who exercises independent judgment in providing health services.

Record requirementThe health service must be recorded in the recipient's record.

Location requirement

Policy Summary

PayerAgency for Health Care Administration

PolicyFlorida Title XIX Federally Qualified Health Center and Rural Health Clinic Reimbursement Plan

Policy CodePolicy 2025-0015

Change TypeModified

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionSubmit FQHC supplemental payment requests quarterly within 30 days after the reported quarter and RHC requests monthly within 15 days after the reported month.

SourceLink

On This Page

For an RHC, the increase or decrease in scope of services is greater than 1 percent.

Effective-date rule

For a scope-of-service increase, the effective date is the latter of the date the service was implemented or 75 days before the request was received.latter of implementation date or 75 days before request receipt
For a scope-of-service decrease, the effective date is the date the service was terminated.

Required documentation

For an FQHC scope-of-service increase, the provider's fiscal year-end audit is submitted before the increase can be approved.
For an RHC request, the most recent audited Medicare cost report and a budgeted cost report documenting the associated increase or decrease in costs are submitted.

If all requested financial data is not received within 12 months after the provider's fiscal year end in which the costs were first affected, the adjustment is granted only after all documentation is satisfied; the adjustment is effective at the beginning of the month in which all information is received by the Agency.12 months after affected fiscal year end

Timely request

FQHC supplemental payment requests are submitted quarterly and received no later than 30 days after the end of the reported quarter.within 30 days after quarter end
RHC supplemental payment requests may be submitted monthly and are received no later than 15 days after the end of the reported month.within 15 days after month end

Payments are reconciled and made on at least a quarterly schedule.

Decrease effective dateThe date the service was terminated

Scope Adjustment Financial Data Minimum

Minimum financial dataAt least six months of actual cost information

Applies toScope-of-service increases or decreases for encounter rate adjustment requests

Supporting documentationThe submitted financial data must demonstrate the costs associated with the scope-of-service change.

Scope Increase Effective-Date Limit

Increase effective dateThe latter of the date the service was implemented or 75 days before the date the request was received

Decrease effective dateThe date the service was terminated

Applies toScope-of-service encounter rate adjustments

Late Documentation Period

Documentation period12 months after the provider's fiscal year end in which the costs were first affected

Late submission consequenceThe request is granted only after all required documentation has been satisfied.

Resulting effective dateAny rate adjustment is effective at the beginning of the month in which all information was received by the Agency.

Billing Rule

Submit supplemental payment requests on schedule

Submit supplemental payment requests to Florida Medicaid within the applicable deadline or risk delaying the supplemental payment request.

FQHC requests: submit quarterly, no later than 30 days from the end of the reported quarter.
RHC requests: requests may be submitted monthly, no later than 15 days from the end of the reported month.

Billing Rule

Agree to the Alternative Payment Methodology

To receive the applicable Alternative Payment Methodology reimbursement, each FQHC or RHC must agree to the APM in accordance with section 1902(bb)(6) of the Social Security Act. The additional funding is subject to annual reconciliation.

Denial Risk

Address audit adjustments and misrepresentation

Repay or receive reimbursement for overpayments or underpayments identified through desk or field audits, including adjustments resulting from encounter-rate reporting or calculation errors. Intentionally misrepresented information may result in suspension from the Florida Medicaid program.

Repayments must follow the applicable statutory and federal requirements.
Audit-determined adjustments may be reimbursable to the provider or to AHCA, as appropriate.

The health service must be completed on site.

Encounter Rate

DefinitionThe approved Medicaid reimbursement rate based on the Medicaid prospective payment system.

Payment basisThe rate is based on the Medicaid prospective payment system.

ProgramMedicaid

Medicaid Prospective Payment System

DefinitionA reimbursement method in which Medicaid payment is made based on a predetermined, fixed amount.

Payment basisPayment is determined in advance rather than based on the provider's actual charge for each service.

ProgramMedicaid

Rate Period

BeginningOctober 1 of a calendar year

EndingSeptember 30 of the next calendar year

DurationOne calendar-year rate period spanning October 1 through September 30.

Eligible Medicaid Recipient

EligibilityAn individual determined eligible pursuant to federal and state law by the Florida Department of Children and Families, AHCA, or SSA on behalf of AHCA.

Covered careThe individual is eligible to receive medical or allied care, goods, or services for which AHCA may make payments under the Florida Medicaid program.

EnrollmentThe individual is enrolled in the Florida Medicaid program.