This product is supported by Florida Department of Children and Families Substance Abuse and Mental Health Program Office funding.

America’s Voice for Community Health Care The National Association of Community Health Centers (NACHC) represents Community and Migrant Health Centers, as well as Health Care for the Homeless and Public Housing Primary Care Programs and other community-based health centers. Founded in 1971, NACHC is a nonprofit advocacy organization providing education, training and technical assistance to health centers in support of their mission to provide quality health care to medically underserved populations.

The NACHC Mission To promote the provision of high quality, comprehensive and affordable health care that is coordinated, culturally and linguistically competent, and community directed for all medically underserved populations. Visit us at www.nachc.com

What is a Health Center: The Ins and Outs of Health Centers Jaime Hirschfeld Director, Health Center Growth and Development September 26, 2013

Agenda Overview of What a Health Center is and Terms History of Health Centers Benefits of Health Centers Health Center Program Requirements Funding Process Resources

Director, Health Center Growth & Development Who Am I? Jaime Hirschfeld, M.Ed. Director, Health Center Growth & Development Joined NACHC in 2011 Worked at the Ohio Association of Community Health Centers for 6 years as the Director of Education and Membership Oversees the DentaQuest Strengthening the Oral Health Safety Net Grant Health Center Community Development

Getting to Know You… My current role is: Executive Director/ CEO COO Site Supervisor Direct Care Provider Other

Getting to Know You… My organization currently partners with the local health center: True False

Getting to Know You… My organization has applied for health center funding: True False We are considering it

What is a Health Venter? Private, charitable, tax-exempt non-profit organization OR public entity (direct or co-applicant arrangement). Community-based provider of high quality, affordable primary care and preventive services regardless of insurance status or ability to pay. Must serve a medically underserved area (MUA) or medically underserved population (MUP) designated by HHS.

Five Characteristics of a CHC Must Serve a high needs area (designated Medically Underserved Area or Population) Comprehensive healthcare and related services based on the needs of the community Open to all regardless of insurance status or ability to pay Governed by the community (51% of board members MUST be patients) Held to strict accountability and performance measures for clinical, financial and administrative operations by Health Resources and Services Administration(HRSA)

Health Center Program: Background Began with President Johnson's "War on Poverty" and civil rights movement Created in 1965 as part of the Office of Economic Opportunity First two neighborhood health centers: Boston (1965) Mound Bayou, Mississippi (1967) In 1975, Congress authorized neighborhood health centers as “community and migrant health centers” Later adding public housing and homeless

Health Center Program: Background The Health Centers Consolidation Act of 1996 Combined these separate authorities (community, migrant, homeless, and public housing) under Section 330 of the Public Health Service Act (PHSA) to create the consolidated health centers program Currently, over 1,200 health centers deliver care through over 9,000 service delivery sites in every state and territory.

Types of FQHCs Community Health Centers serve a variety of underserved populations and areas (Section 330) Migrant Health Centers serve migrant and seasonal agricultural workers (Section 330g) Healthcare for the Homeless Programs reach out to homeless individuals and families and provide primary care and substance abuse services (Section 330h) Public Housing Primary Care Programs serve residents of public housing and are located in or adjacent to the communities they serve (Section 330i)

What is a Federally Qualified Health Center (FQHC)? An entity defined under Medicare and Medicaid statutes that: Eligible for reimbursement by Medicare, Medicaid, and CHIP using specific payment methodologies Falls under one of the following categories: Meets requirements of the Health Center Program and receives a grant under section 330 of the Public Health Service Act. Meets requirements of the Health Center Program but does not receive a grant under section 330 of the Public Health Service Act. Qualifies as an outpatient health program or facility operated by a tribe or tribal organization.

FQHC vs. Health Center A Federally Qualified Health Center (FQHC) is an entity defined under Medicare and Medicaid statutes that: Is eligible for reimbursement by Medicare, Medicaid, and CHIP using specific payment methodologies Falls under one of the following categories: Meets requirements of the Health Center Program and receives a grant under section 330 of the Public Health Service Act. Meets requirements of the Health Center Program but does not receive a grant under section 330 of the Public Health Service Act. Qualifies as an outpatient health program or facility operated by a tribe or tribal organization.

FQHC vs. Health Center Health Center is a designation that comes from Health Resource Services Administration (HRSA). While many people use the terms FQHC and health center interchangeably, technically they are not transposable.

Look-alike Health centers that operate and provide services consistent with all statutory, regulatory, and policy requirements that apply to Health Center Program grantees, but do not receive funding under section 330 Organizations eligible for look-alike designation: public or nonprofit private entities including tribal, faith-based, and community-based organizations *Applicants must propose to expand their network of service delivery sites to serve new underserved populations.

Look-alike vs. Health Center Grantee Benefit Health Center Grantee Look-alike Grant Funding YES NO Rolling, non-competitive application Eligible for Medicaid Prospective Payment System (PPS) Eligible for Medicare cost-based reimbursement Access to 340B drug pricing Eligible for Federal Tort Claims Act medical malpractice insurance Vaccines for Children Eligible for supplemental HRSA funding Automatic Health Professional Shortage Area (HPSA) Designation

Funding for CHCs Federal Grant – around $650,000 for basic grant but many opportunities exist to increase funding thereafter (New Access Points, Service Expansion, and Expanded Medical Capacity) All federal $ to be used exclusively for the care of the uninsured. Medicaid – Prospective Payment System (PPS). A reimbursement mechanism roughly based upon the cost of a patient encounter. Rate is increased yearly by Medicare Economic Index (MEI). Medicare – Prospective Payment System – similar to the Medicaid system, cost report is filed yearly with CMS. Private Insurance – accepted just like private practices. Uninsured – Patients below 200% of the Federal Poverty Level (FPL) pay on a sliding fee scale based upon ability to pay.

Income Sources for Health Centers

Impact of Affordable Care Act on Payer Source 2009 Payer Source For State Post Reform (2015) Patients by Payer Source Medicare 8% Exchange 17% Uninsured 19% Uninsured 37% Medicare 10% Medicaid/ CHIP 40% 3rd Party 10% Medicaid/ CHIP 44% 3rd Party 15% 2014 Medicaid expansion will cover up to 133% FPL, and Health Insurance Exchanges will be up and running.

Health Center Benefits Access to Federal grant funds to support the costs of uncompensated care (Health Center Program grantees only) Federal Tort Claims Act (FTCA) malpractice coverage (Health Center Program grantees only) Federal Loan Guarantee Program (Health Center Program grantees only) Eligibility for: Enhanced reimbursement under Prospective Payment System (PPS) or other state-approved alternative payment methodology for services provided under Medicaid Cost-based reimbursement for services provided under Medicare Participation in the 340B (discounted) Drug Pricing Program Health Professional Shortage Area Designation and participation in National Health Service Corps

Federal Tort Claims Act (FTCA) Health Centers complete a “deeming” process to access Federal Tort Claims Act (FTCA) a medical malpractice insurance coverage. Upon approval, medical malpractice insurance is paid for by the federal government and allows: CHCs to apply derived savings into additional care for the uninsured population; Providers to stay in specialty fields where medical malpractice premiums have skyrocketed (i.e. OB/GYNs). FTCA coverage is especially important in rural areas where access to care is already difficult and specialty providers are even harder to recruit and retain.

Who are Health Center Patients? Collectively, health centers are the Health Care Home for 22.3 Million Americans Nearly all patients are low income 3 out of 4 have family incomes at or below poverty 1 out of every 3 patients are uninsured 2 out of every 5 patients depend on Medicaid Half of health center patients reside in rural areas, with the other half living in economically depressed inner city communities

Who are Health Center Patients? Health Center Patients Are Predominately Low Income Source: Federally-funded health centers only. 2010 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. Note: Federal Poverty Level (FPL) for a family of three in 2010 was $17,600. (See http://aspe.hhs.gov/poverty/08poverty.shtml.) Based on percent known. Percents may not total 100% due to rounding.

Who are Health Center Patients? Most Health Center Patients are Uninsured or Publicly Insured Other public may include non-Medicaid SCHIP and state-funded insurance programs. Source: Federally-funded health centers only. 2010 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. Note: Percents may not total 100% due to rounding.

19 Health Center Program Requirements 19 key program requirements that are divided into four core components: Service to medically underserved areas/population or need Scope of services Management and finance Governance http://bphc.hrsa.gov/about/requirements/

Health Center Program: Fundamental Principles Private non-profit or public agency that must serve a high need community or population Medically underserved area (MUA Medically underserved population (MUP) Governed by a community board of which a majority (at least 51%) are health center patients who represent the population served Provide comprehensive primary care services and enabling/ supportive services Services are available to all with fees adjust based on income level and family size Establish linkages and collaborative arrangements Meet performance and accountability requirements regarding administrative, clinical and financial operations

What are MUA, MUP and HPSA Designations? To qualify for health center funding, your center must be located in, or plan to serve, an MUA or MUP locale. Federal designations that allow the government to prioritize communities for certain programs include: Medically Underserved Areas (MUA) Medically Underserved Populations (MUP) Health Professional Shortage Area (HSPA)

What are MUA, MUP and HPSA Designations? Populations eligible for this designation are: Low-Income and/or Medicaid Eligible populations Migrant workers Linguistically Isolated Groups Homeless Residents of Public Housing

Poll My organization is in a MUA, serves a MUP or has a HPSA designation: True False I do not know

Governance Health centers must be governed by a community board that: Is composed of at least nine but no more than 25 members Has a majority (at least 51%) of health center patients who represent the population served Should have enough members to represent all segments of the community, areas of expertise required, and complete the work needed

Consumer/ Patient Board Member Uses the health center for their primary source of health care (or dental care) Legal guardian of a consumer who is a dependent child or adult, or a legal sponsor of an immigrant Reasonably represents the demographics of the individuals served by the health center in terms of Ethnicity Race Sex Socioeconomic status, if possible

Non-Consumer Board Members 49% or less of the board composition Be representatives of the area served by the center Have specific expertise Maximum of half of these board members (49 percent or less) cannot earn more than 10 percent of their income from the health care industry Have at least enough members to: Represent all segments of the community Represent all areas of expertise required Complete the work needed without overloading some or all of the board members

Additional Governance Requirements Meet once a month Select the services provided by the center Schedule hours of service Approve the annual budget Select the health center Executive Director/ CEO Establish general policies for the center

Poll: My organization currently has a governing board: True False

Poll: Our governing board is made up of a patient majority: True False We do not have a board

Comprehensive Primary Care Services Health centers must provide: Comprehensive primary care services Enabling/supportive services The goal is that the health center is able to promote access to health care to the population it serves!

Examples of Required Comprehensive Primary Care Services Pediatric, Well Child Care & Immunizations Internal Medicine & Geriatric Services Obstetrics, Prenatal, & Perinatal Services Gynecology and Family Planning Emergency and Preventive Dental Services

Examples of Enabling/Supportive Services Patient Education and Outreach Patient Transportation Interpretive Services Medicaid Eligibility Services Substance Abuse and Mental Health Services Health centers provide these services directly or have written arrangements and referrals in place to ensure that they are meeting the needs of the populations served.

Poll: Our organization provides more than behavioral health services: True False

Ability to Pay Health centers must provide services that are available to all with fees adjusted based upon ability to pay. Ability to pay is determined by a patient's annual income and family size according to the most recent U.S. Department of Health & Human Services Federal Poverty Guidelines.

2013 Federal Poverty Income Guidelines for the 48 Contiguous States and the DC

Sliding Fee Scale Must be made available for all individuals and families with an annual income below 200 percent of the poverty guidelines Must provide for a full (100 percent) discount for all individuals and families with an annual income below 100 percent of the poverty guidelines May include nominal fees collected from individual or families with an annual income at or below 100 percent of the poverty guidelines when imposition of such fees is consistent with project goals

Sliding Fee Scale Details Be prepared by the health center and reviewed by the board annually Be consistent with locally prevailing rates or charges Be designed to cover the reasonable costs of operation Have a corresponding schedule of discounts (or sliding fee scale) to be applied to the payment of such fees, in which discounts are adjusted on the basis of the patient's ability to pay

Sliding Fee Scale Details Post signs announcing the availability of discounts in a prominent and accessible location Make patients aware of the discount option Make all reasonable effort to obtain reimbursement from third party payers

Sliding Fee Scale Example It is the policy of ABC Healthcare to provide essential medical services, regardless of the patient’s ability to pay. Discounts are offered based upon household income and size. A sliding fee schedule is used to calculate the basic discount and is updated each year using the Federal poverty guidelines. Once approved, the discount will be honored for six months, after which the patient must reapply. A completed application including required documentation of the home address, household income, and insurance coverage must be on file and approved by the business office before a discount will be granted. If the applicant appears to be eligible for Medicaid, a written denial of coverage by Medicaid may also be required. Adolescent patients seeking confidential care are exempt from the application process, and services are provided at the nominal rate.

Poll: We charge and bill for our services: True False

Interested in Becoming a Health Center? Follow this link to our guide http://tiny.cc/NewStartFQHC

Poll: After listening to the first part of this presentation, I want to apply for health center or look-alike status: True False I do not know

Applying for Health Center Grant Program Funding Health centers receive grant funding through section 330 funding. Open funding opportunities are announced on: HRSA web site: http://www.hrsa.gov/grants/default.htm Grants.gov: http://grants.gov/

Applying for Health Center Grant Program Funding The following types of grants are available to health centers: New Access Points Grants (NAP) Expanded Medical Capacity Grants (EMC) Service Expansion Grants Service Area Competition Grants (SAC) *New Access Points Grants and Service Area Competition Grants are the only ones available to organizations that do NOT currently receive section 330 grant funds.

Timing/Availability of Grant Funding Health Center grants are made available when funding is available rather than on a regular cycle making: Planning extremely unpredictable Grant giving highly competitive Organizations applying for section 330 grants have 120 days to become operational and compliant with the 19 Program Requirements. REGISTER EARLY WITH GRANTS.GOV

Standard Review Criteria While each opportunity may have additional requirements, the standard review criteria are: Needs assessment Response Evaluative measures Impact Resources/capabilities Support requested

No Grant Funds Available??? Look-alike Status Designation is available at any time, on a rolling basis The application is non-competitive Applicants can provide feedback during the process The review process takes about four months.

Look-alike Application and Requirements Look-alikes must meet the same program requirements as health centers that receive section 330 grant funds and are eligible for many of the same benefits, except, those that are applying for Look-Alike Status must: Be fully compliant Have at least one full-time permanent service delivery site operating at least 40 hours per week Be operational for at least six months prior to application

Partners There are several state and national partner organizations who support health centers through training and technical assistance: NACHC PCAs PCOs

The NACHC Mission To promote the provision of high quality, comprehensive and affordable health care that is coordinated, culturally and linguistically competent, and community directed for all medically underserved populations. Mission of the T/TA Department: To provide education, training, technical assistance, and leadership development to health center staff, boards, and others to promote excellence and cost-effectiveness in health delivery practice and community governance.

NACHC Services Policy and Advocacy Research Primary Care Association (PCA) / Health Center Controlled Network (HCCN) Support Training and Technical Assistance (T/TA) Community Development Emergency Management Financial Operations and Management Governance Human Resources Health Information Technology Clinical Leadership

State/Regional Primary Care Associations (PCAs) PCAs are private, non-profit organizations that provide a wide spectrum of services individualized to state needs and may include: Training and technical assistance to health centers Support for the development of health centers in their state Operational diagnostics and support Leadership Development Group Purchasing Programs Workforce Retention and Recruitment Lobbying and Advocacy with state regulatory and legislative entities And More….!

Contact Information Jaime Hirschfeld jhirschfeld@nachc.com (301) 347-0400 ext 2091

Additional Resources Bureau of Primary Health Care: http://bphc.hrsa.gov/ HRSA: www.HRSA.gov NACHC: www.nachc.com List of PCAs: www.nachc.com/nachc-pca-listing.cfm Conferences: www.nachc.com/conferences-and-trainings.cfm Trainings: www.nachc.com/nachc-pca-listing.cfm Health Center Information: www.nachc.com/health-center-info.cfm

Questions?