Requirements of a Federally Qualified Health Center or FQHC Look

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Transcript Requirements of a Federally Qualified Health Center or FQHC Look

Ryan White & Health Care Reform

Future Paths for Integration, Expansion, and Innovation Harvard Law School Health Law and Policy Clinic & Treatment Access Expansion Project In collaboration with: AIDS Foundation of Chicago, National AIDS Strategy Coalition, HIV Prevention Justice Alliance, HIV Medicine Association, Project Inform, Ryan White Medical Providers Coalition

This webinar is sponsored by the Treatment Access Expansion Project (, AIDS Foundation of Chicago, HIV Prevention Justice Alliance, and the Coalition for a National AIDS Strategy ( One of many groups supporting the Coalition’s efforts, Bristol-Myers Squibb has generously sponsored this teleconference, with no review or editorial discretion as to topics or content discussed.

Presentation Outline

• Introduction (and moderating)

Robert Greenwald, Harvard Law School & TAEP

• Part 1: The Changing Landscape

Amy Killelea, Harvard Law School & TAEP

• Part 2: Opportunities for Sustaining/Expanding HIV Care under Health Care Reform

Andrea Weddle, HIVMA & Amy Killelea

• Part 3: Next Steps and Advocacy Efforts

Anne Donnelly, Project Inform

• Part 4: Resources

Part 1

The Changing Landscape

The Future of Ryan White Funded HIV Care under Health Care Reform

Ryan White Funding is Not Enough to Meet Increased Need

Number of People Living with AIDS in the US vs. Ryan White Funding (adjusted for inflation)

What Does Health Care Reform Mean for HIV/AIDS Care and Treatment?

Medicaid Expansion

 Starting in 2014, no longer have to be disabled to be eligible for Medicaid 

Most low-income, uninsured people will now be automatically eligible for Medicaid

(133% FPL = ~ $14K for an individual and $29K for family of four)  Includes a new Essential Health Benefits Package

What Does Health Care Reform Mean for HIV/AIDS Care and Treatment?

Increased Access to Private Insurance

 Pre-existing Condition Insurance Program  State-based exchanges (starting in 2014) • Subsidies for those with income up to 400% FPL  Elimination of many harmful and discriminatory insurance practices • E.g., No higher premiums based on health  Individual and employer mandates

What Does Health Care Reform Mean for HIV/AIDS Care and Treatment?

New Investments in Care and Prevention

 • Community health center expansion $11 billion over five years  Prevention and Public Health Fund • $750 million in FY 2011  Health care workforce investments

What Does Health Care Reform Mean

     2008 Ryan White Program

for Ryan White Clients?

 2014 Medicaid Expands to most people up to 133% FPL 30% were uninsured 68% had incomes at or below 100% FPL 22% had incomes between 101% and 200% FPL  Eliminates disability requirement Private 34% were insured through Medicaid 12% had private insurance Health Care Reform  Insurance Subsidies to purchase insurance for people with income up to 400% FPL  Elimination of pre existing condition exclusions

What Does Health Care Reform Mean for Ryan White Providers?

Starting in 2014, the Role for Ryan White Will Change Because Most People Will Have Insurance Coverage

 Greatest challenges • • Medicaid’s provider reimbursement rates New reimbursement systems  Greatest opportunities • • • Relief to an increasingly underfunded Ryan White Program New investments in community-based care Potential for new reimbursement systems and funding streams for Ryan White providers (RWPs)

Part 2

Opportunities for Sustaining/Expanding HIV Care under Health Care Reform

1.) Making the Medicaid Expansion Work for People with HIV and AIDS

Implementation Opportunities

Essential Health Benefits   Floor of benefits available to newly-eligible beneficiaries Must be comprehensive enough to meet the needs of people with HIV and AIDS and other chronic conditions • Comprehensive prescription drug benefit • • Mental health, substance abuse, and support services Prevention Demonstration Projects  Center for Medicare and Medicaid Innovation (CMMI) coordinated and integrated care projects • Medicaid Health Home program • HRSA/CMS evaluation of RW model of care Outreach  RWPs will continue to be first line of information for newly eligible Medicaid beneficiaries

Opportunities Beyond Health Care Reform for Building a Robust HIV Care System  Health Homes • Medical home certification for RWPs  Provider Reimbursement (fee for service and managed care) • Advocate for enhanced rates for HIV providers • Ensure payment for coordination of care  • • Medicaid Defense Protect optional benefits and provider payment levels Limit exceptions to “maintenance of effort” requirements  Ongoing Ryan White Advocacy • To provide essential wrap-around care, treatment and support services

2.) Making Private Insurance Reforms Work for People with HIV and AIDS

Designing Insurance Exchanges that Meet the Care and Treatment Needs of People with HIV and AIDS  Essential Health Benefits Package • Among others, ensuring comprehensive prescription drug benefit, mental health and substance abuse services • Maximizing access to support and prevention services  Integration of RWPs into provider networks  Patient navigation  Maximize potential of 3rd-party billing and reimbursement

3.) Integrating HIV/AIDS Care and Treatment into the Health Center Program

Leverage New Investments Health Care Reform Allocates $11 Billion to Community Health Centers New Access Point Grants Enhanced Training and Technical Assistance $11 Billion Expansion of Services Construction and Renovation

Overlapping Populations of FQHCs and Ryan White Funded Clinics

Overlapping Missions of FQHCs and Ryan White Funded Clinics 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.

The Basics

What is an FQHC?

 A community health center that meets federal requirements and • • • • receives significant grant funding and other federal benefits Serves federally designated medically underserved population or located in federally designated medically underserved area Serves all residents of service area regardless of ability to pay Provides full continuum of primary and preventive care services Governed by an independent community-based board of directors, a certain percentage of which must be health center consumers  Funding to become a new FQHC grantee only available when New Access Point grant funding announcements are released by HRSA What is an FQHC Look Alike?

 A community health center that satisfies FQHC requirements and receives many, but not all, FQHC benefits, but has not been awarded a grant • Look Alikes are in a good position to apply for grant funding (and full FQHC status) when new grants are announced by HRSA

Becoming or Collaborating with an FQHC Who can Apply?

 A private non-profit or public agency that serves a federally designated medically underserved area or population How Can I Collaborate with an Existing FQHC?

 Referral arrangement  Established/contractual arrangements • Co-location arrangement • Purchase of services agreement  Sub-recipient arrangement

Benefits and Challenges

Benefits of becoming/collaborating with an FQHC include:

 FQHC specific grant funding  Enhanced Medicaid and Medicare reimbursement for services  Opportunity for RWPs to continue to provide wrap-around services  Opportunity for RWPs to ensure smooth transitions  Opportunity to fill gaps in HIV medical provider expertise and experience

Challenges of becoming/collaborating with an FQHC:

 Changing mission and expanding services beyond HIV and AIDS  Requires bridges between Ryan White and Health Center Programs  Restructuring governing board  Costly and labor-intensive application process  In collaboration agreement, difficult for FQHC benefits (e.g., cost-based reimbursement) to go to collaborating partners

4.) Other Opportunities for Integrating HIV/AIDS Care, Treatment, and Providers into Broader Health Care Systems

Other Opportunities  Ensure that HIV/AIDS providers benefit from National Health Service Corps investments  Build on federal investment in developing HIV centers of excellence  Seek demonstrations, pilot projects, and grants • E.g., new payment mechanisms for coordinated care • • E.g., medical home demonstration projects E.g., Community Transformation Grants

Part 3

Next Steps and Advocacy Efforts

What You Can Do

 Educate yourself about health care reform and what it means for the HIV/AIDS community  Defend health care reform! • • E.g., Medicaid Expansion, Prevention and Public Health Fund Join the HIV Health Care Access Working Group  Maximize effective state implementation of health care reform • E.g., Sound implementation of Medicaid expansion and private insurance exchanges • Connect with other health advocates working on the state level  Start conversations on collaboration/ integration with FQHCs • With Your board – Your community – Neighboring FQHCs   Ensure you are accessing all existing resources Stay tuned • • Follow up T/A and webinars Guidance from HRSA

What Questions Should the HIV/AIDS Community Consider Going Forward?  Is my organization (or where I get my care) poised to maximize funding streams/opportunities?

 What populations are currently served and what does it mean to expand to others?

 What services are currently provided and is there the capacity to expand?

 What models of care are already in place and do these models fit into health care reform models?

 What FQHCs exist in the area and what is the relationship with them?

• What HIV services do they provide (e.g., HIV testing)

Part 4

Available Resources

What Resources Are Available?

 HRSA Resources,

o Planning grants o T/A  NACHC Resources,

o Trainings and T/A, including FQHC 101 o Guidance documents  Primary Care Organizations  Treatment Access Expansion Project,

 HIV Medicine Association,

What Resources Are Available?

Health Care Reform Resources  Kaiser Family Foundation,

 FamiliesUSA,


What Resources Are Available?

AIDS Advocacy Resources  Coalition for NHAS,

 HIV Prevention Justice Alliance,

 Dose of Change – AIDS Advocacy Skills Building,