1. (a) Application of deductible.

   1. (1) Medicare payment for RHC services begins only after the beneficiary has incurred the deductible.
   2. (2) Medicare payment for services covered under the FQHC benefit is not subject to the usual Part B deductible.

2. (b) Application of coinsurance. Except for preventive services for which Medicare pays 100 percent under § 410.152(l) of this chapter, a beneficiary's responsibility is either of the following:

   1. (1) For RHCs that are authorized to bill on the basis of the reasonable cost system—

      1. (i) A coinsurance amount that does not exceed 20 percent of the RHC's reasonable customary charge for the covered service; and

      2. (ii)

         1. (A) The beneficiary's deductible and coinsurance amount for any one item or service furnished by the RHC may not exceed a reasonable amount customarily charged by the RHC for that particular item or service; or
         2. (B) For any one item or service furnished by a FQHC, a coinsurance amount that does not exceed 20 percent of a reasonable customary charge by the FQHC for that particular item or service.

   2. (2) For FQHCs authorized to bill under the PPS, a coinsurance amount which is 20 percent of the lesser of—

      1. (i) The FQHC's actual charge; or
      2. (ii) The FQHC PPS rate for the covered service.

3. (c) Application of deductible and coinsurance for RHCs and FQHCs paid on the basis of the special payment rule described under § 405.2462(j).

   1. (1) For RHCs, the coinsurance amount is determined as described in paragraph (b)(1) of this section; or

   2. (2) For FQHCs, the coinsurance amount is 20 percent of the lesser of—

      1. (i) The FQHC's actual charge; or
      2. (ii) The payment determined under § 405.2462(j)(2).

[71 FR 55345, Sept. 22, 2006, as amended at 79 FR 25474, May 2, 2014; 80 FR 71371, Nov. 16, 2015; 88 FR 82176, Nov. 22, 2023; 89 FR 98553, Dec. 9, 2024]