1. 2012 Ryan White Grantee Meeting
Guidance to Developing Collaborations with Federally Qualified Health Centers
November 27, 2012
2012 Ryan White Grantee Meeting
Jacki Leifer, Esq.

2. Disclosures
This continuing education activity is managed and accredited by Professional Education Services Group. The information presented in this activity represents the opinion of the authors. Neither PESG, nor any accrediting organization endorses any commercial products displayed or mentioned in conjunction with this activity.
Commercial support was not received for this activity.
Jacki Leifer, Esq. has no financial interest or relationships to disclose.

3. Disclaimer
This presentation has been prepared by the attorneys of Feldesman Tucker Leifer Fidell LLP. The opinions expressed in these materials are solely their views.
The materials are being issued with the understanding that the authors are not engaged in rendering legal or other professional services. If legal advice or other expert assistance is required, the services of a competent professional should be sought.

4. Learning Objectives
At the conclusion of this activity, the participants will be able to:
Describe options for developing collaborative arrangements with community partners.
Understand relevant policies and rules regarding collaborative arrangements.
Identify strategies to develop community collaborations.

5. Core Requirements for FQHCs
FQHCs must meet certain core requirements:
Be a public or private nonprofit entity
Serve a medically underserved area (MUA) or medically underserved population (MUP)
Provide, or arrange for the provision of, the required services, which include comprehensive primary and preventive health care services (including essential ancillary and enabling services) across all life cycles; may provide certain supplemental services
Have a schedule of charges designed to cover reasonable costs of operation and consistent with locally prevailing (community) rates
Have a corresponding schedule of discounts
Adjusted based on ability to pay for all uninsured and underinsured patients earning annual incomes below 200% of the Federal Poverty Level
Full discounts or “nominal” charges for uninsured and underinsured persons earning annual incomes at or below 100% of the Federal Poverty Level

6. Core Requirements for FQHCs
The FQHC must:
Have a governing board (comprised of 9-25 individuals)
Majority must be active consumers of the FQHC services and demographically representative of the populations served by the FQHC
Non-consumer Board members must represent the community served and be selected for expertise in areas such as finance and banking, legal community affairs, etc.
The Board must autonomously exercise all authorities and approvals for the FQHC, including selecting the CEO, approval of the annual budget, approval of financial management policies and internal control systems, personnel policies, and health care policies (including scope, schedule and location of services, eligibility for services), compliance policies, Q/A, and more.

7. Compliance with 45 CFR Part 74
Section 330 grantees must comply with the requirements and standards set forth in 45 CFR Part 74 regarding:
Procurement of goods and services utilizing Federal funds (in whole or in part)
Acquisition, management and disposition of property and equipment, acquired or improved with Federal funds (in whole or in part)

8. FQHC Benefits: Section 330 Grantees and Look-Alikes
Opportunity to apply for Federal grant funding
Access to favorable drug pricing under Section 340B of the Public Health Service Act
Access to fair payment under the Prospective Payment System (PPS) or other state-approved alternative payment methodology for Medicaid and CHIP services and cost-based reimbursement for services provided under Medicare; “wraparound” payments for difference between Medicaid managed care capitation and PPS
Reimbursement by Medicare for "first dollar" of services rendered to Medicare beneficiaries, i.e., deductible is waived
Access to providers through the National Health Service Corps

9. FQHC Benefits: Section 330 Grantees Only
Access to Federal Tort Claims Act (FTCA) coverage, in lieu of purchasing malpractice insurance for “eligible persons”
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 populations served by the FQHC
Access to Federal loan guarantees of the principal and interest on loans made by non-Federal lenders for the costs of developing and operating managed care and practice management networks or plans, which are majority owned and/or controlled by Section 330-supported FQHCs
Access to grant support/loan guarantees for capital improvements

10. Why Collaborate? Overlapping Missions Health Center Program Mission
Health centers are community-based and patient-directed organizations that serve populations with limited access to health care regardless of ability to pay.
Ryan White Program Mission
The Ryan White Program supports cities, states, and local community-based organizations that provide HIV-related services to those who do not have sufficient health care coverage or financial resources for coping with HIV disease. Ryan White fills gaps in care not covered by other sources.
Source: “Ryan White & Health Care Reform”, Harvard Law School Health Law and Policy Clinic & Treatment Access Expansion Project. Available at

11. Why Collaborate? Overlapping Patients
Source: “Ryan White & Health Care Reform”, Harvard Law School Health Law and Policy Clinic & Treatment Access Expansion Project. Available at

12. Why Collaborate? Funding v. Need
Number of People Living with AIDS in the US vs. Ryan White Funding (adjusted for inflation)
Source: “Ryan White & Health Care Reform”, Harvard Law School Health Law and Policy Clinic & Treatment Access Expansion Project. Available at

13. Health Reform: Incentives to Collaborate
Creates the $11 billion Community Health Center Trust Fund
Authorizes $1.5 billion in FQHC construction funding over five years
Requires that FQHCs be paid no less than FQHC Medicaid PPS rates from private plans participating in State-based health insurance exchanges
Recent CMS rulemaking softens this requirement
May expand Medicaid eligibility to cover all non-elderly adults up to 133% of FPL, effective 2014 (depends on state)
Increases access to private health insurance and does not permit discriminatory practices
Eliminates higher premiums based on health
Insurers cannot rescind coverage for adults or children except in cases of fraud or intentional misrepresentation of a material fact
Insurers can no longer impose a lifetime dollar limit on essential health benefits

14. Health Reform: Impact on Ryan White
Starting in 2014, most individuals who previously receiving care through the Ryan White program will be eligible for other programs created under the ACA
Medicaid Expansion
State Insurance Exchanges
State Pre-Existing Condition Insurance Plans (PCIPs)
Private Health Insurance
Under these programs, while the overall number of insured will likely rise, Ryan White patients could see their benefits decrease, co-pays increase, reduced access to HIV prevention services, and decreased access to medications
In addition, some Ryan White patients will remain uninsured or ineligible for insurance

15. New Models of Care
As the health care system heads towards greater coordination and integration, FQHCs and Ryan White programs nationwide are moving into new models of care
Patient-Centered Medical Homes (PCMHs)
Personal physicians
Whole person orientation
Coordinated and integrated care
Safe and high-quality care through evidence-informed medicine, appropriate use of health information technology, and continuous quality improvements
Expanded access to care
Payment that recognizes added value from additional components of patient-centered care

16. New Models of Care Other collaborative models
Community Transformation Grants, Collaborative Care Networks, Community Health Teams
Medicare and Medicaid Accountable Care Organization (ACO) and Bundled Payment Demonstrations
Health Center-Controlled Networks

17. Range of Collaboration Models
Referral Arrangements
Co-location Referral Arrangements
Lease of Personnel and Services
Establishment of New Site
Subrecipient Arrangements

18. Referral Arrangements
Patients
Ryan White Program
Referral
FQHC
The referral provider agrees to furnish services to referred FQHC patients
Referral provider is financially, clinically and legally responsible and is solely liable for claims related to services
Referral provider bills and collects payment for the services rendered (note: If providing services as a referral provider, the FQHC/RWP must ensure compliance with Sec. 330 and RWP requirements, as applicable)

19. Referral Arrangements
Do the FQHC and RWP have sufficient personnel to see additional patients?
Will patients have reasonable access to the services provided by the FQHC/RWP?
How will referrals be made and managed?
Will the RWP agree to accept all patients referred to it by the FQHC, regardless of ability to pay, subject to capacity limitation?
Will the FQHC agree to accept all patients referred to it by the RWP, regardless of ability to pay, subject to capacity limitation?

20. Co-Location Referral Arrangements
FQHC
FQHC’s Facility
Ryan White Program Facility
Co-Located Provider
FQHC
Referral
Ryan White Program
Are separate and distinct patient care delivery systems maintained?
How will referrals be made and managed?
Is there a lease of space and/or equipment?
Can patients distinguish between the FQHC and the Ryan White program (e.g., separate signage, entrances, etc.)?
Are providers separately identified?
Similar considerations about fee schedule and schedule of discounts as under Referral Arrangements: the entity providing the service will determine the relevant fee schedule and schedule of discounts in accordance with its applicable requirements

21. $ Lease of Personnel/Services FQHC Ryan White Program (“Vendor”)
FQHC policies &
procedures
Ryan White Program
(“Vendor”) $
FQHC Patients
FQHC leases clinical and/or administrative services from RWP to be provided to FQHC’s patients on behalf of health center
FQHC is financially, clinically and legally responsible for the services purchased
Alternative: RWP may lease clinical and/or administrative services from the FQHC. However:
No FTCA
Services provided by leased FQHC personnel are outside of the FQHC’s scope of project

22. Lease of Personnel/Services
Is it clear that the FQHC is responsible for billing/collecting from third parties and/or patients and retains all revenue for all services provided by leased personnel?
Is the FQHC paying a fair market value fee?
Do the leased personnel satisfy applicable qualification requirements?
Is it clear that the leased providers must furnish services consistent with FQHC’s policies, procedures, standards and protocols?
Does the FQHC have authority to evaluate and remove the leased personnel?
The RWP must consider whether the lease of capacity arrangement is consistent with the requirements under the Ryan White program.

23. Integration of RW Provider & FQHC
Transfer of Operational Authority
New service(s)?
New site(s)?
Subsidiary?
Merger?
Ryan White Provider
FQHC Scope
Caution: Must obtain HRSA’s approval to add a new site to the FQHC’s scope project. Consider whether RWP grant may transfer to FQHC.

24. Integration of RW Provider & FQHC
Can the FQHC satisfy the requirements to add the new site(s) (and services, if applicable) to the FQHC’s scope of project?
Has the FQHC calculated the costs (i.e., space/equipment costs, start-up costs, uncompensated costs) and revenue associated with operating the new site and/or new service?
Can the FQHC operate the new site at a breakeven budget?
Note: In order to break even, community benefit grant support is typically needed to cover the uncompensated care costs associated with serving low-income uninsured and underinsured populations (more on this soon…)
Will assets (facility/equipment) be sold to the FQHC?
Will medical records transfer to the FQHC?
How will patients be notified of the transfer or the establishment of the new site?

25. Transitioning HIV/AIDS Care to a CHC
In 2010, Sonoma County, California’s largest HIV provider—the health department’s HIV/AIDS clinic—was going to close for budget reasons
The County’s HIV/AIDS services were transitioned, along with its funded grant programs, to two networked health centers: Santa Rosa Community Health Centers and West County Health Center
Patients and the former county HIV care program benefited in several ways:
Patients have access to broader primary care services through the health center
The health center uses electronic health records—something that was not in place under the county system
The health center, in turn, benefited from absorbing the new HIV/AIDS care program, gaining insights into the patient-centered medical home concept in managing chronic conditions for all patients
New model is financially sustainable
Source: National HIV/AIDS Strategy, “Improving HIV/AIDS Care in the Health Center Community”, Summary of a HRSA/BPHC Grantee TA Call (January 31, 2011).

26. Community Benefit Grants
Any project that involves adding a site(s) to the FQHC’s scope of project without a New Access Point award or other Section 330 funding supplement must have a pro forma that reflects, at worst, a break-even budget
Costs
Revenue
Most common approach is an award of a Community Benefit Grant from the other provider in order to cover the FQHC’s losses associated with serving additional low-income uninsured and underinsured patients

27. Community Benefit Grants
Health Center Safe Harbor under Federal Anti-Kickback statute: final OIG rule issued October 4, 2007 [42 C.F.R. § (w)]
Purpose: protect from prosecution under the federal anti-kickback law certain arrangements between FQHC grantees and providers/suppliers of goods, items, services, donations and loans
that contribute to the FQHC’s ability to maintain or increase the availability, or enhance the quality, of services provided
to the FQHC’s medically underserved patients

28. Subrecipient Agreement
Caution: Some RW grants do not allow the grantee to serve only as the administrative agent
RW Grantee
Subrecipient Agreement $
FQHC

29. Subrecipient Agreement
Will the FQHC be able to comply with the RW grant requirements while still adhering to the Section 330 requirements?
Will the FQHC be able to satisfy both the RW program and the Section 330 requirements pertaining to fee schedule and schedule of discounts?
Will all FQHC patients have access to the services supported by the RW program?
Will the RWP be operated as an other line of business, outside of the FQHC’s scope of project?

30. 19 Health Center Program Requirements
FQHCs must maintain compliance with all core requirements:
Requirement #10: Health center exercises appropriate oversight and authority over all contracted services
Requirement #11: Health center makes effort to establish and maintain collaborative relationships with other health care providers, including other health centers, in the service area of the center

31. HRSA Affiliation Policies
Affiliation agreements / contracted arrangements cannot threaten or limit the FQHC’s autonomy (See HRSA Affiliation Policy Information Notice (“PIN”) 97-27)
Governance: under all affiliation arrangements, the FQHC 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 FQHC 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

32. Getting to “Yes”
Memorandum Of Agreement (including appropriate confidentiality protections)
Planning and development
Joint Steering Committee
Planning Teams (e.g., clinical, operational, financial)
Due diligence review
Definitive agreements
Board approvals
Regulatory approvals

33. Jacqueline C. Leifer, Esq.
Questions?
Jacqueline C. Leifer, Esq.
Feldesman Tucker Leifer Fidell LLP th Street N.W. – Suite 400 Washington, D.C
(202)

34. Obtaining CME/CE Credit
If you would like to receive continuing education credit for this activity, please visit: