National Association of Community Health Centers, Inc. 1

America’s Voice for Community Health Care 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 people. 2 National Association of Community Health Centers, Inc.

Background: What is an FQHC? Medicare and Medicaid statutes define a provider type: “Federally Qualified Health Center” (FQHC) –Respectively, Social Security Act §1861(aa)(4) and §1905(l)(2)(B) Entity that receives a grant under section 330 of the Public Health Service Act – Health Center Program. Entity that is determined by DHHS to meet requirements to receive funding without actually receiving a grant (i.e., FQHC Look-Alike). Entities that are outpatient health programs or facilities operated by a tribe or tribal organization under the Indian Self-Determination Act or by an Indian organization receiving funds under Title V of the Indian Health Care Improvement Act. 3 National Association of Community Health Centers, Inc.

Health Center Program: Background The Health Center Program (authorized under section 330 of the Public Health Service (PHS) Act) includes: Community Health Center Program – section 330(e) Migrant Health Center Program – section 330(g) Health Care for the Homeless Program – section 330(h) Public Housing Primary Care Program – section 330(i) National Association of Community Health Centers, Inc. 4

Federal Scope of Project: Brings together all of the requirements by defining the who, what, where and how of providing access to care in your community Defines what the total grant-related project budget (including program income and other non-section 330 funds) and related benefits support –How/where Federal grant dollars will be used –Scope of FTCA coverage (in general) –Site information for the 340B Drug Pricing Program –Approved delivery sites and services for enhanced Medicaid and Medicare reimbursement Scope of Project defined in PIN National Association of Community Health Centers, Inc.

Scope of Project: Five Core Elements Service Area: Geographic area served by the center Services: Form 5-Part A Target Population: Medically underserved community or population served by the center Providers: Individual health care professionals who deliver services on behalf of the center on a regularly scheduled basis Scope of Project Sites: Form 5-Part B Other Activities/Locations: Form 5-Part C 6 National Association of Community Health Centers, Inc.

Why Become an FQHC? Benefits for Section 330 Grantees Only Access to Federal grants –To support the costs of uncompensated care –To support the costs of planning/developing and operating practice management or managed care networks/plans –Cannot be used for construction Access to Federal loan guarantees –For the costs of developing and operating managed care and practice management networks or plans –For capital improvements 7 National Association of Community Health Centers, Inc.

Why Become an FQHC? Benefits for Section 330 Grantees Only Eligible for Federal Tort Claims Act (FTCA) coverage, in lieu of purchasing malpractice insurance Safe Harbor under the Federal anti-kickback statute for certain arrangements with other providers or suppliers of goods, services, donations, loans, etc., which benefit the medically underserved population served by the FQHC. 8 National Association of Community Health Centers, Inc.

Why Become an FQHC? Benefits for Grantees and FQHC Look-Alikes Eligible 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 Access to favorable drug pricing under section 340B of the PHS Act 9 National Association of Community Health Centers, Inc.

Why Become an FQHC? Benefits for Grantees and FQHC Look-Alikes 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 Right to have “outstationed” Medicaid eligibility workers Reimbursement by Medicare for "first dollar" of services rendered to beneficiaries, i.e., deductible is waived 10 National Association of Community Health Centers, Inc.

Why Become an FQHC? Benefits for Grantees and FQHC Look-Alikes Access to providers through the National Health Service Corps if the health center's service area is designated a Health Professional Shortage Area (HPSA). Access to the Federal Vaccine For Children program. 11 National Association of Community Health Centers, Inc.

Threshold Eligibility Requirements Must be either a private, charitable, tax-exempt nonprofit organization OR public entity (direct or co-applicant arrangement) Must serve a medically underserved area (MUA) or medically underserved population (MUP) designated by DHHS –Required for CHC Programs –Not required for MHC, HCH or PHPC Programs 12 National Association of Community Health Centers, Inc.

Program Requirements: Services Must provide either directly or through contract or established arrangement: –Required “primary health“ services Basic primary and preventive care services Supplementary services including referrals to other providers (specialists when medically indicated) and health related- services (substance abuse and mental health services) Case management services (counseling referral, and follow- up) and other services designed to assist patients in establishing eligibility for programs that provide financial assistance 13 National Association of Community Health Centers, Inc.

Program Requirements: Services Must provide either directly or through contract or established arrangement: Enabling services including outreach, transportation and translation Education regarding the availability and proper use of health services –Additional health services as appropriate including behavioral and mental health and substance abuse services, recuperative care and environmental health services 14 National Association of Community Health Centers, Inc.

Program Requirements: Payment for Services Must provide services to all residents of the service area regardless of ability to pay Must have a schedule of charges designed to cover the reasonable costs of operation and consistent with locally prevailing rates Must have a corresponding schedule of discounts appropriate for the target population –Adjusted based on ability to pay for individuals/families with annual incomes at or below 200 percent of poverty –Full discounts (or, at most, a nominal fee) for individuals/families with annual incomes at or below 100 percent of poverty 15 National Association of Community Health Centers, Inc.

Program Requirements: Governing Board Composition Must be governed by a community-based Board of Directors –Must have between 9 and 25 members –A minimum of 51% of Board members (at least a majority) must be active consumers of health center services –Consumer Board members Should live in the service area Must reasonably represent the patient population served in terms of demographic factors such as race, ethnicity and gender 16 National Association of Community Health Centers, Inc.

Program Requirements: Governing Board Composition –Non-consumer Board members Should live or work in the service area Should be representative of the community served and be selected for expertise in areas such as finance and banking, legal community affairs, etc. No more than one half of non-consumer members can derive more than 10 percent of their income from the health care industry –If funded under more than one section 330 program, must demonstrate appropriate representation from each of the populations served by the health center 17 National Association of Community Health Centers, Inc.

Program Requirements: Governing Board Composition Key policy clarification: to be considered a consumer Board member for composition purposes, the individual –Should utilize the health center as their principal source of primary care and should have used health center services within the last two years –Can be a legal guardian of a consumer who is a dependent child or adult, or a legal sponsor of an immigrant consumer 18 National Association of Community Health Centers, Inc.

Waiver of Certain Composition and Procedural Requirements GOVERNING BOARD COMPOSITION AND MEETINGS WAIVERS: –Waivers allowed for programs funded ONLY under 330(g), 330(h) and/or 330(i), provided that an appropriate plan is presented to assure consumer input into the governance process –Waivers are not allowed for programs receiving 330(e) funding 19 National Association of Community Health Centers, Inc.

Program Requirements: Governing Board Procedures Governing Board should establish appropriate procedures –Selection procedures that allow for a self- perpetuating Board (i.e., the Board elects itself) –Selecting, evaluating and dismissing the Executive Director/Chief Executive Officer –Establishing and approving health care policies and procedures –Establishing and approving personnel policies and procedures 20 National Association of Community Health Centers, Inc.

Program Requirements: Governing Board Authorities Key authorities (cont.) –Establishing and approving financial management practices –Hiring the auditor and accepting the annual audit report –Evaluating the FQHC’s activities –Assuring compliance with applicable federal, state and local law, regulation and policy –Engaging in strategic and operational planning 21 National Association of Community Health Centers, Inc.

Program Requirements: Management CEO must be directly employed by the health center –Preferred that management team members are directly employed, but good cause exceptions are available Must have a direct line of authority from the Board to the CEO who delegates as appropriate Must have effective administrative and clinical leadership, systems and procedures, including a strong management team 22 National Association of Community Health Centers, Inc.

Program Requirements: Clinical Operations Must employ a clinical staff that is multi-disciplinary, and culturally sensitive and linguistically appropriate –Preferred that majority of primary care clinicians are directly employed, but good cause exceptions are available Expected to establish appropriate linkages and collaborative arrangements with other community-based health and social services providers, agencies, programs: referral arrangements for continuum of care, admitting privileges, after-hours coverage Must have ongoing quality improvement programs and patient tracking systems 23 National Association of Community Health Centers, Inc.

Program Requirements: Clinical Operations Key policy clarification: any and all collaborations must –Maintain integrity of the health center program –Retain Board’s autonomous and independent decision-making with regard to full scope of authorities –Retain Board’s compliance with composition and selection requirements –Comply with other applicable laws, regulations and policies (including HRSA affiliation policies - PINS #97-27, #98-24) 24 National Association of Community Health Centers, Inc.

Program Requirements: Financial and Information Systems Must have a financial system that accurately reflects the financial performance of the organization and assures viability and competitiveness Must maximize non-Federal revenue (Medicaid, Medicare, third party, patients, etc.) Must arrange for an annual independent audit to assess financial performance Must have an IT system that is able to collect, organize and analyze data for reporting and to support management decision-making 25 National Association of Community Health Centers, Inc.

26 COLLABORATIONS SO WHAT DO WE WANT TO DO AND WHAT ARE THE IMPLICATIONS?? 1.We want to collaborative with an FQHC to provide some services for their patients - that works here’s what you can and cannot do: If they are “required services” there must be written agreement with the partner provider that can be: a referral arrangement Partner will provide defined care to health center patients who are referred to it by health center regardless of ability to pay Partner is financially, clinically and legally responsible and is solely liable for damages related to services Partner bills and collects payment for the services Patients receiving services are partner’s patients for the referred services 26 National Association of Community Health Centers, Inc.

27 COLLABORATIONS SO WHAT DO WE WANT TO DO AND WHAT ARE THE IMPLICATIONS?? 1.We want to collaborative with an FQHC to provide some required services for their patients - that works here’s what you can and cannot do: –Or you can have a contractual agreement: Whereby the partner provides services to health center’s patients on behalf of health center and is paid either on a hourly or negotiated fee basis Health center is financially, clinically and legally responsible for the services purchased Patients receiving services are health center patients - FQHC owns medical records and does all billing and collections 27 National Association of Community Health Centers, Inc.

28 AFFILIATIONS AND INTEGRATED SERVICES SO WHAT DO WE WANT TO DO AND WHAT ARE THE IMPLICATIONS?? 1.We want to have an umbrella affiliation with an FQHC to provide some services for their patients - that works here’s what you can and cannot do: –Develop a broad continuum of activities that the FQHC and partner provide for each other –Identify mutual obligations and benefits –Cannot abridge any of the FQHC Governing Board autonomies or authorities –Cannot violate any of the FQHC’s requirements or obligations 2.We want to develop integrated services model - for services in the FQHCs scope of project: –Integrated services/programs are operated under health center umbrella and the health center assumes operational and financial authority for services/programs Partner’s clinicians are either integrated into health center’s workforce or purchased by health center through a Lease of Clinical Capacity May require “Transition Agreement” Cannot impact health center board’s autonomy and compliance 28 National Association of Community Health Centers, Inc.

HOWEVER UNDER ANY AND ALL COLLABORATION MODELS THE INTEGRITY OF THE FQHC’S CORPORATE STRUCTURE MUST BE MAINTAINED –No parent/subsidiary or similar structures (e.g., Sole Member) unless Health center retains all Board selection and composition requirements, and exercises all prescribed authorities and The structure is specifically approved by HRSA 29 National Association of Community Health Centers, Inc. 29 National Association of Community Health Centers, Inc.

HOWEVER UNDER ANY AND ALL COLLABORATION MODELS Governance: under all affiliation arrangements, board must remain compliant with all Section 330- related selection and composition requirements and retain all prescribed authorities –No other entity or appointed individual may Select the majority of health center board members, non- consumer members, or members of the Executive Committee, or function as board chair Preclude the selection, or require the dismissal, of board members not appointed by that party Have overriding approval authority, veto authority or “dual majority” authority 30 National Association of Community Health Centers, Inc. 30 National Association of Community Health Centers, Inc.

HOWEVER UNDER ANY AND ALL COLLABORATION MODELS Management and Finance –No other entity/individual can employ Executive Director/CEO –No other entity/individual can employ CFO and/or CMO, subject to good cause exception (PIN #98-24) Health Services/Clinical Operations –No other entity/individual can employ the majority of health center’s PCPs, subject to good cause exception (PIN #98-24) –Non-exclusivity: no other entity/individual can control health center’s relationships with other providers unless control will not impact health center’s ability to collaborate and coordinate with other local providers 31 National Association of Community Health Centers, Inc. 31 National Association of Community Health Centers, Inc.

A RELATED BUT DIFFERENT QUESTION Can we come under the FQHC’s “umbrella” and then spin-off on our own in a couple of years?? Once an organization merges with an FQHC they become a part of that FQHC corporation, that is they cease to exist as a separate entity. The FQHC governing board and management assume control over the “merged” organization. Spinning off a site is not under the control of the FQHC but rather involves significant negotiation with HRSA. 32 National Association of Community Health Centers, Inc. 32 National Association of Community Health Centers, Inc.

SALIENT QUESTIONS FOR HIV/AIDS CLINICS IN TRANSITIONING Mission changes Population changes Services changes Budgeting/Billing changes 33 National Association of Community Health Centers, Inc. 33 National Association of Community Health Centers, Inc.

Key Documents: Grant-Related Requirements Medicaid & Medicare Statutes (Social Security Act 1905(1)(2)(B)(iii) and 1861(aa)(4)(b) respectively) –Define “Federally Qualified Health Center” as a provider type eligible for enhanced reimbursement under Medicaid and Medicare Grant enabling statute: Section 330 of the Public Health Service Act, as amended by Public Law (October 26, 2002) Program-specific regulations: 42 CFR Part 51c (community health centers) and 42 CFR Part 56 (migrant health centers) 34 National Association of Community Health Centers, Inc.

Key Documents: Grant-Related Requirements DHHS administrative regulations: 45 CFR Part 74, incorporating OMB Circulars A-110, A-122, A-133 (which are codified at 2 CFR Part 215 and Part 230) –Financial and program management systems, including cost principles –Procurement standards –Property and equipment standards –Reporting requirements DHHS Grants Policy Statement 35 National Association of Community Health Centers, Inc.

Key Documents: Grant-Related Requirements Bureau of Primary Health Care (BPHC) Policies –Program Information Notices (PINs) PIN # 98-23: Health Center Program Expectations PINs # & 98-24: Affiliation policies PIN # : Service Area Overlap Policy and Process PIN # : Scope of Project Policy PIN # Specialty Services and Scope of Project –Program Assistance Letters (PALs) Notice of Grant Award (NGA) and special terms and conditions 36 National Association of Community Health Centers, Inc.

Pamela J. Byrnes, PhD Director, Health Center Growth and Development National Association of Community Health Centers, Inc. 37 STAY IN TOUCH