Transcript BPHC Funding Opportunities in Fiscal Year 2002

National Association of
Community Health
Centers, Inc.
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America’s 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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Community Health
Centers, Inc.
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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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Community Health
Centers, Inc.
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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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Community Health
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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
Services: Form 5-Part A
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
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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Community Health
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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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Community Health
Centers, Inc.
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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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Community Health
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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 relatedservices (substance abuse and mental health services)
• Case management services (counseling referral, and followup) and other services designed to assist patients in
establishing eligibility for programs that provide financial
assistance
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Community Health
Centers, Inc.
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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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Community Health
Centers, Inc.
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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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Community Health
Centers, Inc.
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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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Centers, Inc.
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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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Community Health
Centers, Inc.
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Program Requirements: Governing Board
Procedures
Governing Board should establish appropriate
procedures
–Selection procedures that allow for a selfperpetuating 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 FQHC’s 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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Centers, Inc.
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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 Board’s autonomous and independent
decision-making with regard to full scope of
authorities
–Retain Board’s 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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Centers, Inc.
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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??
1.
We want to collaborative with an FQHC to provide some services
for their patients - that works here’s 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 partner’s patients for the referred
services
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Centers, Inc.
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COLLABORATIONS
SO WHAT DO WE WANT TO DO AND WHAT ARE THE IMPLICATIONS??
1.
We want to collaborative with an FQHC to provide some required
services for their patients - that works here’s what you can and
cannot do:
–
Or you can have a contractual agreement:
• Whereby the partner provides services to health center’s
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??
1.
2.
We want to have an umbrella affiliation with an FQHC to provide some services for
their patients - that works here’s 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 FQHC’s 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
Partner’s clinicians are either integrated into health center’s workforce or
purchased by health center through a Lease of Clinical Capacity
May require “Transition Agreement”
Cannot impact health center board’s autonomy and compliance
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HOWEVER UNDER ANY AND ALL
COLLABORATION MODELS
• THE INTEGRITY OF THE FQHC’S 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
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HOWEVER UNDER ANY AND ALL
COLLABORATION MODELS
• Governance: under all affiliation arrangements,
board must remain compliant with all Section 330related selection and composition requirements
and retain all prescribed authorities
– No other entity or appointed individual may
• Select the majority of health center board members, nonconsumer 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
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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
center’s PCPs, subject to good cause exception (PIN #98-24)
– Non-exclusivity: no other entity/individual can control health
center’s relationships with other providers unless control will
not impact health center’s ability to collaborate and coordinate
with other local providers
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A RELATED BUT DIFFERENT
QUESTION
• Can we come under the FQHC’s “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.
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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
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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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Community Health
Centers, Inc.
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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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Centers, Inc.
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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
[email protected]
860-739-9224
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Community Health
Centers, Inc.
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