CMS Publishes CMS 9989 Final Rule: Establishment of Exchanges and Qualified Health Plans

The Centers for Medicare and Medicaid Services (CMS) published Final Rule CMS 9989 on March 27, leaving states flexibility when determining which providers will be classified as “essential community providers” under new federal regulations that dictate the operation of qualified health plans. Led by the National Assembly on School-Based Health Care (NASBHC), several groups had advocated for the inclusion of school-based health centers as essential community providers in the final CMS rule.


As reported in the NASBHC March 2012 newsletter, although the Department of Health and Human Services did not include school-based health centers as essential community providers in the final rule, it did specifically state that the list was “not an exhaustive list and [was not intended] to exclude qualified health plan issuers from contracting with other providers that serve predominantly low-income, medically underserved individuals.” Groups petitioning to be classified as essential community providers will need to work with individual states to achieve that outcome, a situation that has resulted when other federal regulations have been published in support of the Affordable Care Act.

Paradigm is tracking the implementation of Final Rule CMS 9989 in California and the California School Health Centers Association’s continuing efforts to include school-based health centers as essential community providers. This development would present a potential opportunity to encourage the recognition of schools’ role as safety-net health care providers, a lack of which has been a major obstacle to billing for eligible students with third party liability under the LEA Billing Option program.


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Read the final rule CMS 9989…