1. NASBHC: 2011 Financial Survey of State Funding and “Out of the Box “ Financial Strategies for SBHCs Laura Brey NCSCHA Conference, December 3, 2012

2. Our Vision All children and adolescents are healthy and achieving at their fullest potential. Our Mission To improve the health status of children and youth by advancing and advocating for school-based health care Adopted by Board of Directors, January 2009

3. NASBHC Membership Individual $75 ($25 student) A national voice advocating for SBHCs at the Federal level Quarterly newsletter Events calendar Online renewal Free access to NASBHC publications Access to members-only space on NASBHC.org –Searchable member directory –Archived issues of the newsletter –Special member updates –Archived NASBHC Web conferences Free access to NASBHC toolkits Organizational $500 All of the benefits of an individual membership, AND Two individual memberships Access to job board with ability to post positions 50 customizable postcards promoting the SBHC model E-mail updates and action alerts for the entire staff (requires submission of a staff e-mail roster) 3

4. Objectives Review results of nationwide survey of states’ financial support of school-based health centers Discuss innovative ideas of financial support/strategies for school-based health services

5. Total SBHCs in US, 1990-2008 Map: Distribution of SBHCs, 2008

6. Why State Funds Matter Nearly one in two school-based health centers rely on state-directed public funds to help sustain their services.

7. Data Sets Department of Public Health State Policy Survey – Target: State public health agencies (inc. DC, PR) – Objective: assess types and amount of state SBHC funding, technical support and data collection. – Response = 52 agencies (inc. DC, PR) Medicaid State Policy Survey – Target: State Medicaid agencies (inc. DC, PR) – Objective: assess state Medicaid SBHC policies – Reponse Rate = 41 agencies (inc. DC)

8. Department of Public Health State Policy Survey

9. DC States that Fund SBHCs, 2011 FL’s SBHC earmark is specific to a legislative district and is not a statewide program. It is not included in the analysis. State-directed funds for SBHCs (18)

10. 18 States Fund SBHCs 17 collect data from SBHCs 15 convene a statewide network 14 staff a state program office 14 set and monitor SBHC standards

11. Summary of State-Directed Funds FY2011 State Investment # SBHCs funded Grant size/ SBHC Total$89.6M875-- Average$5M49$102,000 High$21.7M223$660,000 Low$271,0003$20,000 n = 18 states

12. Total State-Directed Funds by Source Total for FY2011: $89.6M n = 18 states

13. State SBHCs Funded Total State General Fund Tobacco Settlement Title V MCH Block Grant Other AR 11$ 2,000,000 -- - CO 41$ 1,205,118$ 947,177 - $ 226,122$ 31,819 CT 81 $ 10,728,342$ 10,440,246 Unknown$ 288,096- DC 4$ 2,675,000-$ 2,000,000$ 675,000- DE 28$ 5,200,000 - -- IL 39$ 4,244,600$ 159,800$ 1,958,500$ 1,339,100$ 787,200 IN 3$ 271,000 -- - LA 62$ 7,606,790$ 2,586,308$ 4,792,277$ 228,204 - MA 36$ 2,868,998 - - - MD 68$ 2,700,000 -- - ME 20$ 719,500$ 219,745$ 499,555$ 200- MI 72$ 16,557,000$ 3,557,000 -- $13,000,000 NC 21$ 1,429,812 - -- NM 56$ 5,175,000$ 5,067,000 - $ 80,000 $ 28,000 NY 223$ 21,765,126$19,699,140 - $ 2,065,986 OR 54$ 2,973,497$ 2,033,497- - $ 940,000 TX 6$ 462,500 - - - WV 50$ 1,027,100 - - - Total 875$ 89,609,383 $ 59,935,823$ 9,250,332$ 5,636,208$ 14,787,019 State-Directed Funding for SBHCs By State, FY 2011

14. Note: Total number of school is from 2008-09; SBHC count is from FY2011. Data source: National Center for Education Statistics: http://nces.ed.gov/programs/digest/d10/tables/dt10_102.asp Percent of All Public Schools with State-Directed $ for SBHCs

15. Total State-Directed Funding, 1996-2011 Data sources: Center for Health and Health Care and Schools (1996-2002); NASBHC (2005-2011) Millions

16. Data sources: Center for Health and Health Care and Schools (1996-2002); NASBHC (2005-2011) Number of State Programs Declines; Total State-Directed Funds Increase

17. Data sources: Center for Health and Health Care and Schools (1996-2002); NASBHC (2005-2011) % of SBHCs Funded by State-Directed $ 1996-2011 ? 54%56%51%45% * * NASBHC’s national census of SBHCs for FY2011 is still underway.

18. Data sources: Center for Health and Health Care and Schools (1996-2002); NASBHC (2005-2011) State-Directed SBHC Funds, % Change, 2000-2011 Off the Charts New Mexico 1,194% Michigan 472% Off the Charts New Mexico 1,194% Michigan 472% 50%100%150%200% -50%0%

19. States’ Accountability for SBHC Funds 14 of 18 States set SBHC operating standards as condition of grant funds – States monitor adherence to SBHC standards through combination of paper review and/or in-person site visit All 18 States track SBHC performance indicators All 18 States collect a range of program data 7 of 18 States monitor Medicaid billing practices

20. SBHC Performance Indicators Most Frequently Tracked by States SBHC Performance Indicators Most Frequently Tracked by States Top 5 of 28 choices States that fund SBHCs (n=17)

21. Most Common SBHC Data Collected by States States that fund SBHCs (n=18)

22. How States Value SBHC Contributions to Public Health Mission States that fund SBHCs (n=18)

23. Top Challenges to SBHCs: State Agency Perspective States that fund SBHCs (n=18)

24. State Medicaid Policies and SBHCs

25. State Medicaid Policies Define SBHCs as Provider Type Waive Preauthorization for SBHCs Waive Preauthorization for Specific SBHC Services Managed Care Organizations Required to Reimburse SBHCs Require Billing Uninsured (sliding scale) Delaware Illinois Louisiana Maine New Mexico North Carolina West Virginia Illinois Louisiana North Carolina West Virginia Connecticut Delaware Maine Maryland Michigan New Mexico Illinois Maryland New York West Virginia NOTE: New York SBHCs are carved out from New York’s Medicaid policies.

26. Conditions Required to Bill Medicaid Of the 19 states that fund SBHCs, 13 responded COCTDCILLAMDNCNMNYWV Licensure of SBHC Certification Maintain Comms w/PCP Licensure of Sponsor Agency MCO Credentialing

27. State Medicaid’s View of SBHC Role Of the 19 states that fund SBHCs, 12 responded ARCOCTILLAMDMENCNMNYORWV Prevention Reproductive EPSDT Provider Outreach/Enrollment Acute Care Primary Care

28. Summary Number of states with investments has stabilized over decade 15 states with decade-old program – Only AR, DC, IN and TX joined ranks in last 10 years Funding remains stable – in spite of state revenue woes More work to be done in Medicaid/CHIP to assure payment, role for SBHCs as medical home Future: aligning SBHC strengths with health care reform goals

29. “Out of the Box” Finance Strategies

30. Community Benefit Plans Affordable Care Act requires tax-exempt hospitals and health care organizations to conduct periodic community health needs assessments every three years and adopt plans to meet assessed needs. Include input from persons representative of broad community interests including those with special knowledge or public health expertise. Adopt implementation strategies to meet the community health needs identified through the assessment. Report annually how it is addressing the needs identified in the community health needs assessment and IRS reporting Describe needs not being addressed including reasons why such needs are not being addressed. Many states require tax-exempt hospitals to conduct community needs assessments and develop community benefit plans, in varying degrees of specifications.

31. Community Benefit Assists with maintaining tax exempt status Value of what a tax exempt health care organization is giving back to the community compared to revenue it is collecting Includes programs or activities that provide treatment and/or promote health and healing as a response to identified community needs And meets at least one of the following criteria – Improves access to health care services – Enhances health of the community – Advances medical or health knowledge – Relieves or reduces the burden of government or other community efforts

32. Community Benefit Programs or activities that provide treatment and/or promote health and healing as a response to identified community needs And meets at least one of the following criteria – Improves access to health care services – Enhances health of the community – Advances medical or health knowledge – Relieves or reduces the burden of government or other community efforts Marketing must not be the primary purpose

33. Hospital OPD Facility Fees /Charges Fact : Out Patient Departments (OPDs) of hospitals are reimbursed 80% more for a 15 minute Evaluation and Management Visit than a private physician’s practice Reason: Hospital OPDs are allowed to add facility fees or charges to the rate billed for each visit. This policy is meant to cover the increased costs of delivering these services in a hospital related setting. Result: : Hospitals are purchasing physician practices and converting them to hospital OPDs without changing their location or patient mix. Question : Can hospital sponsored SBHCs add facility charges to their Medicaid bills? Yes, for now CMS 2012 Recommendation: Realign allowed payment rates over a three year period: lowering OPD rates and increasing free standing physician practice rates

34. Federal Qualified Health Center (FQHC) Program Fundamentals Located in or serve a high need community Governed by a community board Provide comprehensive primary care services and supportive services (education, translation, transportation) that promote health care access Provide services available to all based on ability to pay Meet performance and accountability requirements (administrative, clinical, and financial operations0

35. Federal Qualified Health Center (FQHC) Types of Health Centers Grant-supported FQHCs – public and private non-profit health care organizations which meet health center definition and receive funding under Section 330 of the PHS Act Non-grant supported health centers identified by HRSA and certified by CMS as meeting the health center definition under 330 of PHS Act, referred to as “look-alikes” Outpatient health programs/ facilities operated by tribal organizations (Indian Self-Determination Act) or urban Indian organization (under the Indian Health Care Improvement Act)

36. Federal Qualified Health Center (FQHC) 330 grant supported Benefits New starts can request up to $650,000 Access to medical malpractice coverage under Federal Tort Claims Act (FTCA) Prospective Payment System (PPS) or other state-approved Alternative Payment Methodology (APM) for services to Medicaid patients Cost-based reimbursement for services to Medicare patients Drug Pricing Discounts for pharmaceutical products under the 340B Program Access to on-site eligibility workers to provide Medicaid and CHIP enrollment services Access to Vaccines for Children Program for uninsured children Access to National Health Service Corps (NHSC) medical, dental, and mental health providers Eligible for other federal grants and programs

37. Federal Qualified Health Center (FQHC) Non-330 grant funded Benefits Reimbursement under the Prospective Payment System (PPS) or other state- approved Alternative Payment Methodology (APM) for Medicaid services Cost-based reimbursement for services to Medicare patients Drug Pricing Discounts for pharmaceutical products under the 340B Program Access to on-site eligibility workers to provide Medicaid and CHIP enrollment services Health Professional Shortage Area (HPSA ) designation and eligible to apply to receive National Health Service Corps (NHSC) medical, dental, and mental health providers placements