BPHC Funding Opportunities in Fiscal Year 2002

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Americas 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.
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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.

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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)

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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 2008-01

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

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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.

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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 FQHCs activities
• Assuring compliance with applicable federal,
  state and local law, regulation and policy
• Engaging in strategic and operational planning

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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

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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

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Program Requirements Clinical Operations

• Key policy clarification any and all
  collaborations must
• Maintain integrity of the health center program
• Retain Boards autonomous and independent
  decision-making with regard to full scope of
  authorities
• Retain Boards compliance with composition and
  selection requirements
• Comply with other applicable laws, regulations
  and policies (including HRSA affiliation policies
  - PINS 97-27, 98-24)

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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

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COLLABORATIONS

• SO WHAT DO WE WANT TO DO AND WHAT ARE THE
  IMPLICATIONS??
• We want to collaborative with an FQHC to provide
  some services for their patients - that works
  heres 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 partners
  patients for the referred services

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COLLABORATIONS

• SO WHAT DO WE WANT TO DO AND WHAT ARE THE
  IMPLICATIONS??
• We want to collaborative with an FQHC to provide
  some required services for their patients - that
  works heres what you can and cannot do
• Or you can have a contractual agreement
• Whereby the partner provides services to health
  centers 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

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AFFILIATIONS AND INTEGRATED SERVICES

• SO WHAT DO WE WANT TO DO AND WHAT ARE THE
  IMPLICATIONS??
• We want to have an umbrella affiliation with an
  FQHC to provide some services for their patients
  - that works heres 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 FQHCs requirements or
  obligations
• 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
• Partners clinicians are either integrated into
  health centers workforce or purchased by health
  center through a Lease of Clinical Capacity
• May require Transition Agreement
• Cannot impact health center boards autonomy and
  compliance

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HOWEVER UNDER ANY AND ALL COLLABORATION MODELS

• THE INTEGRITY OF THE FQHCS 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

National Association of Community Health Centers,
Inc.
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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

National Association of Community Health Centers,
Inc.
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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 centers PCPs, subject to good
  cause exception (PIN 98-24)
• Non-exclusivity no other entity/individual can
  control health centers relationships with other
  providers unless control will not impact health
  centers ability to collaborate and coordinate
  with other local providers

National Association of Community Health Centers,
Inc.
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A RELATED BUT DIFFERENT QUESTION

• Can we come under the FQHCs 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.

National Association of Community Health Centers,
Inc.
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SALIENT QUESTIONS FOR HIV/AIDS CLINICS IN
TRANSITIONING

• Mission changes
• Population changes
• Services changes
• Budgeting/Billing changes

National Association of Community Health Centers,
Inc.
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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 107-251 (October 26, 2002)
• Program-specific regulations 42 CFR Part 51c
  (community health centers) and 42 CFR Part 56
  (migrant health centers)

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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

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Key Documents Grant-Related Requirements

• Bureau of Primary Health Care (BPHC) Policies
• Program Information Notices (PINs)
• PIN 98-23 Health Center Program Expectations
• PINs 97-27 98-24 Affiliation policies
• PIN 2007-09 Service Area Overlap Policy and
  Process
• PIN 2008-01 Scope of Project Policy
• PIN 2009-02 - Specialty Services and Scope of
  Project
• Program Assistance Letters (PALs)
• Notice of Grant Award (NGA) and special terms and
  conditions

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STAY IN TOUCH

• Pamela J. Byrnes, PhD
• Director, Health Center Growth and Development
• pbyrnes_at_nachc.com
• 860-739-9224