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

2. 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.

3. 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

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

5. 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

6. 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

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

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

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

10. 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.

11. 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)

12. 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

13. 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.

14. 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)

15. 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.

16. 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.

17. 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.

18. 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.

19. 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

20. 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.

21. Income Sources for Health Centers

22. 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.

23. 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

24. 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.

25. 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

26. Who are Health Center Patients?
Health Center Patients Are Predominately Low Income
Source: Federally-funded health centers only 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 Based on percent known. Percents may not total 100% due to rounding.

27. 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 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.
Note: Percents may not total 100% due to rounding.

28. 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

29. 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

30. 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)

31. 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

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

34. 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

35. 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

36. 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

37. 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

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

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

40. 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!

41. 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

42. 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.

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

44. 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.

45. 2013 Federal Poverty Income Guidelines for the 48 Contiguous States and the DC

46. 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

47. 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

48. 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

49. 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.

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

51. Interested in Becoming a Health Center?
Follow this link to our guide

52. 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

53. 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:
Grants.gov:

54. 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.

55. 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

56. 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

57. 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.

58. 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

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

60. 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.

61. 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

62. 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….!

63. Contact Information
Jaime Hirschfeld (301) ext 2091

64. Additional Resources
Bureau of Primary Health Care:
HRSA:
NACHC:
List of PCAs:
Conferences:
Trainings:
Health Center Information:

65. Questions?