pin 2009-06: fqhc look-alike guidelines and application

1. 01-20-2010 1 PIN 2009-06: FQHC Look-Alike Guidelines and Application Twyla Adams, MHS, Branch Chief Valerie Kolick, Public Health Analyst Office of Policy and Program Development Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care

2. 01-20-2010 2 Objectives

3. 01-20-2010 3 FQHC Look-Alike Basics

4. 01-20-2010 4 Definition of FQHCs Medicare and Medicaid statutes define the provider type �Federally Qualified Health Center� (FQHC) (Social Security Act �1861(aa)(4) and �1905(l)(2)(B) respectively) HRSA administers two types of FQHCs: An entity that receives a grant under section 330 of the Public Health Service Act (PHSA). An entity that is determined by DHHS to meet requirements to receive funding without actually receiving a grant.

5. 01-20-2010 5 Fundamental Principles Guiding principles in the FQHC Look-Alike Program include: Private non-profit or public entities that must serve a high need community or population (i.e., medically underserved areas or medically underserved populations). Governed by a community board of which at least a majority (51%) are health center patients who represent the population served.

6. 01-20-2010 6 Fundamental Principles Provide comprehensive primary care services as well as enabling and supportive services such as education, translation, and transportation that promote access to health care. Services are available to all with fees adjusted based upon ability to pay. Meet other performance and accountability requirements regarding administrative, clinical, and financial operations.

7. 01-20-2010 7 Benefits of FQHC Look-Alike Status Eligible for: Enhanced reimbursement under Prospective Payment System or other state-approved alternative payment methodology for services provided under Medicaid. Cost-based reimbursement for services provided under Medicare. Access to favorable drug pricing under section 340B of the PHSA. Right to have �outstationed� Medicaid eligibility workers.

8. 01-20-2010 8 Benefits of FQHC Look-Alike Status Safe harbor under the Federal anti-kickback statute for waiver of co-payments to the extent a patient is below 200% of Federal income poverty guidelines. Reimbursement by Medicare for "first dollar" of services rendered to beneficiaries (i.e., deductible is waived). Access to providers through the National Health Service Corps. Access to the Federal Vaccine For Children Program. Do not receive section 330 grant funds. Receive section 330 grant funds. Do not have coverage under the Federal Tort Claims Act (FTCA). Have coverage under the FTCA.Do not receive section 330 grant funds. Receive section 330 grant funds. Do not have coverage under the Federal Tort Claims Act (FTCA). Have coverage under the FTCA.

9. 01-20-2010 9 FQHC Look-Alike Program Administration The FQHC Look-Alike Program is operated under an intra-agency agreement between HRSA and CMS. HRSA is responsible for: Assuring compliance with requirements under section 330 of the PHSA. Making a recommendation to CMS for designation as an FQHC Look-Alike. CMS has final authority to designate an applicant as an FQHC Look-Alike.

10. 01-20-2010 10 FQHC Look-Alike Data Trends1991-2009 Since 1991, the FQHC Look-Alike Program has grown from 28 to 78 organizations. It reached its peak in 2005, when there were 124 organizations. This number has decreased as FQHC Look-Alikes have been successful in obtaining section 330 grant funds. Between 2002 and 2009, about 40% (n=137) of FQHC Look-Alikes that applied for section 330 grants funds were successful in obtaining them. HRSA receives annually about 31 FQHC Look-Alike new designation applications; about 16 are designated.

11. 01-20-2010 11 Policy Information Notice 2009-06

12. 01-20-2010 12 Goals of PIN 2009-06 To enhance clarity in conveying HRSA�s expectations for applicants. To better align FQHC Look-Alike application requirements with section 330 application requirements.

13. 01-20-2010 13 PIN Drafting Process Two drafts of the revised application guidance were released for 60-day public comment in the fall of 2007 and 2008. Public comments are reflected in PIN 2009-06.

14. 01-20-2010 14 Effective Date of PIN 2009-06 PIN 2009-06 was issued on September 22, 2009. Starting April 1, 2010, organizations are strongly encouraged to use PIN 2009-06 when submitting applications; however, after September 22, 2010, organizations must use PIN 2009-06. From now through September 21, 2010, organizations may use PIN 2003-21 and its accompanying amendments or PIN 2009-06 when submitting applications.

15. 01-20-2010 15 Changes in PIN 2009-06 Additions include: Renewal of Designation application must be submitted at least every five years. Organizations may exclusively serve special populations as authorized under section 330 of PHSA: Section 330(g) � Migrant/Seasonal Agricultural Workers; Section 330(h) � Homeless Persons; and/or Section 330(i) � Residents of Public Housing. Allowance of governance waivers of the 51% consumer/patient majority and monthly meeting governance requirements for organizations exclusively serving the above special populations.

16. 01-20-2010 16 Changes in PIN 2009-06 Other additions include: Required submission of Health Care and Business Plans with clinical and financial performance measures. New forms and tables. Revisions include: Revised forms and tables. Effective date for an approved change in scope of project request. Program narrative format. Deletion of Letter of Interest.

17. 01-20-2010 17 FQHC Look-Alike Application Types New Designation Renewal of Designation Recertification Request for Change in Scope of Project

18. 01-20-2010 18 Application Process Applications for new designation are accepted on a rolling basis. Applications are only accepted during specified application cycles. Applications undergo internal review by HRSA staff. Applications undergo a review by an objective review committee.Applications for new designation are accepted on a rolling basis. Applications are only accepted during specified application cycles. Applications undergo internal review by HRSA staff. Applications undergo a review by an objective review committee.

19. 01-20-2010 19 Developing FQHC Look-Alike Applications

20. 01-20-2010 20 Tips Perform a thorough needs assessment early, including coordinating with other FQHCs in the area. Check to ensure that information throughout the application is consistent. Clearly demonstrate and document that the organization meets each program requirement. Review, review, review the application before submitting it!

21. 01-20-2010 21 Key Resources Health Center Program: Section 330 of the PHSA (42 USC � 254b) Medicaid & Medicare Statutes (Social Security Act �1905(l)(2)(B) & �1861(aa)(4) respectively) Program Regulations (42 CFR Parts 51c & 56c)

22. 01-20-2010 22 Contact Information Twyla Adams, MHS Branch Chief Health Center Systems Branch Office of Policy and Program Development 301-594-4300 Twyla.Adams@hrsa.hhs.gov

23. 01-20-2010 23 Contact Information Valerie Kolick Public Health Analyst Health Center Systems Branch Office of Policy and Program Development 301-594-4300 Valerie.Kolick@hrsa.hhs.gov

24. 01-20-2010 24 Questions?