Ryan White 2012 Grantee Meeting November 28, 2012 What Does It Take to Become an FQHC? presented by: Jacqueline C.
Download ReportTranscript Ryan White 2012 Grantee Meeting November 28, 2012 What Does It Take to Become an FQHC? presented by: Jacqueline C.
Ryan White 2012 Grantee Meeting November 28, 2012 What Does It Take to Become an FQHC? presented by: Jacqueline C. Leifer, Esq. of FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. History of the Health Centers Program • 1964: Congress passed Title VI of the Economic Opportunity Act • Created the Office of Economic Opportunity • First health center model, combining community resources with Federal funds to establish neighborhood clinics • 1965: First two “neighborhood health center” demonstration projects funded in Boston and Mound Bayou, Mississippi FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 2 www.FTLF.com FQHC Defined • A Federally Qualified Health Center (FQHC) is a public or non-profit private entity that provides primary and preventive health care, including enabling services, to a medically underserved population or residents of a medically underserved area FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 3 www.FTLF.com Health Center Facts • • • • Currently, there are over 1,200 Federally Qualified Health Centers (FQHCs) serving 20 million patients (38% of whom have no health insurance and another 36% of whom are reliant on Medicaid) at 7,500 sites located in all of the 50 states, Puerto Rico, the District of Columbia, the U.S. Virgin Islands and Guam FQHC patients: • 71% have incomes at or below the Federal Poverty Level • 50% live in rural areas, and the other 50% tend to live in depressed inner city areas FQHCs derive revenue from public and private insurance, as well as federal, state, and local grants and contracts • Public Health Service Act grants account for 18.3% of FQHC revenue • Medicaid accounts for 37% of FQHC revenue The Patient Protection and Affordable Care Act (PPACA) provides funding to double current patient capacity to 40 million by 2015 • Estimated cost savings created by health centers • Up to $122 billion in total health care costs would be saved between 2010 and 2015 • As much as $55 billion for Medicaid over the five-year period ($32 billion in savings for the Federal government, with the rest to states) FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 4 www.FTLF.com FQHC Scope of Project • Defines the who, what, where and how of providing access to care in the community • Defines what the total grant-related project budget (including program income and other non-section 330 funds) and related benefits support • How and where Federal grant dollars and pledged program income/resources will be used • Scope of Federal Tort Claims Act (FTCA) coverage (in general) • Site information for the 340B Drug Pricing Program • Approved delivery sites and services for enhanced Medicaid and Medicare reimbursement FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 5 www.FTLF.com Benefits Available to Section 330 Grantees and Look-Alikes • Opportunity to apply for Federal grants, including expanded medical capacity and direct services grants, to support the otherwise uncompensated costs of furnishing primary and preventive health care and enabling services to medically underserved communities • Access to reimbursement under the Prospective Payment System (PPS) or other state-approved alternative payment methodology (which is predicated on a cost-based reimbursement methodology) for Medicaid and CHIP services and cost-based reimbursement for services provided under Medicare; “wraparound” payments for difference between Medicaid and CHIP managed care capitation and PPS; wraparound on Medicare managed care payments effective FY 2006 and on CHIP payments effective FY 2010 • There are site certification requirements under Medicare, and additional site certifications may apply under Medicaid • Access to favorable drug pricing under Section 340B of the Public Health Service Act FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 6 www.FTLF.com Benefits Available to Section 330 Grantees and Look-Alikes • Reimbursement by Medicare for "first dollar" of services rendered to Medicare beneficiaries, i.e., deductible is waived • Safe harbor under the Federal anti-kickback statute for waiver of co-payments to the extent a patient’s income is below 200% of Federal poverty guidelines • Access to providers through the National Health Service Corps • Access to the Federal Vaccine For Children program and eligibility to participate in the Pfizer Sharing the Care Program FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 7 www.FTLF.com Benefits Available to Section 330 Grantees Only • Access to 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 populations served by the FQHC • Access to grant support/loan guarantees for capital improvements FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 8 www.FTLF.com FQHC Scope of Project Five Elements • Service Area: Geographic area served by the center • Target Population: Medically underserved community or population served by the center • Providers: Individual health care professionals who exercise independent judgment and deliver services on behalf of the center on a regularly scheduled basis • Services – see next slides • Service Sites – see next slides FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 9 www.FTLF.com Scope of Project: Services • Health Resources and Services Administration (HRSA) expects FQHCs to have a system of care that • Ensures access to a comprehensive scope of primary and preventive services, as well as enabling services and, as appropriate and necessary, additional health services, either directly or through established written arrangements and referrals • Assists in providing access to other comprehensive health and social services, including inpatient, specialty, and ancillary care FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 10 www.FTLF.com Scope of Project: Services • Service delivery model must include • Locations that are reasonably accessible and appropriate to the target population and the community as a whole • Hours of operation that • Result in services being reasonably available and accessible • Meet the specific needs of the target population • Manner of service delivery that ensures access for all life cycles of the target population • Directly on-site • Contractual agreements • Formal (written) referral agreements • Informal referral arrangements (non-required services only) • Professional coverage for when the center is closed FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 11 www.FTLF.com Scope of Project: Service Sites • Any location where a FQHC provides primary health care services to a defined service area or target population • Must meet all of the following conditions • FQHC generates face-to-face encounters which are documenting in the patients’ medical record • Providers exercise independent judgment • Services are provided directly by or on behalf of the FQHC, whose governing Board retains control and authority over the provision of the services at the location • Services are provided on a regularly scheduled basis (note – unless State law requires otherwise, no minimum number of hours per week required to be a site) FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 12 www.FTLF.com Scope of Project: Service Sites • Service sites include • • • • • Permanent (year round, fixed location) Seasonal (less than year round, fixed location) Intermittent (limited period of time and change locations) Mobile medical/dental vans Migrant voucher screening sites FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 13 www.FTLF.com Core Requirements: Governance • HRSA expects FQHCs to have a governing body that • Assumes full authority and oversight responsibilities • Maintains compliant size, composition, and meeting schedules • Carries out legal and fiduciary responsibilities • Establishes appropriate committee structure • Provides opportunities for Board training and development FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 14 www.FTLF.com Governance Requirements • Distinguishing feature of FQHCs is governance by a Governance Requirements community-based Board • Size should be between 9 – 25 members, and appropriate for the complexity of organization • A minimum of 51% of Board members (at least a majority) must be active consumers of the FQHC’s services • No Board member can be an employee or a spouse, child, parent or sibling (by blood or marriage) of an employee • Executive Director may serve as an ex-officio non-voting member of the Board FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 15 www.FTLF.com Governance Requirements • Composition • Consumer Board members • Receive health care services at the health center • Must, as a whole, reasonably represent the patient population served in terms of demographic factors such as race, ethnicity and gender FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 16 www.FTLF.com Governance Requirements • Composition (cont.) • Non-consumer Board members • Should be representative of the community served and be selected for expertise in areas such as finance and banking, legal, community affairs, etc. • Should live or work in the service area • No more than one half of non-consumer members can derive more than 10 percent of their income from the health care industry FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 17 www.FTLF.com Governance Requirements • Governing Board should establish appropriate procedures • Monthly meeting schedule (required) and minutes, which are approved at subsequent meeting • Selection procedures that allow for a self-perpetuating Board (i.e., the Board elects itself) • Appropriate committees and committee meeting schedules • Board orientation, training and development • Board-approved policy (or Bylaws provision) managing actual or potential conflicts of interest by Board members, employees, consultants and those who furnish goods/services to the FQHC • Disclosure • Recusal from voting (and possibly discussion) FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 18 www.FTLF.com Governance Requirements • Waivers for governing Board composition and monthly meeting requirements • Waivers allowed for programs funded ONLY under 330(g) (migrant and seasonal), 330(h) (homeless) and/or 330(i) (residents of public housing), provided that there is a showing of “good cause” and an appropriate plan is presented to assure consumer input into the governance process • Waivers are not allowed for programs receiving 330(e)(community health center) funding FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 19 www.FTLF.com Governance Requirements • Community-based Board must autonomously exercise certain key authorities • Selecting, evaluating and dismissing the Executive Director • Establishing health care policies and procedures • Locations and hours of services • Scope and availability of services • Quality of care audit procedures • Establishing personnel policies and procedures • • • • FELDESMAN TUCKER LEIFER FIDELL LLP Selection and dismissal procedures Salary and benefit scales Employee grievance procedures Equal opportunity practices © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 20 www.FTLF.com Governance Requirements • Key authorities (cont.) • Establishing and approving financial management practices • System to assure accountability for center resources and monitoring of organizational assets • Annual project budget and plan • Center priorities • Eligibility for services including criteria for partial payments schedules • Long-term financial planning • Reviewing regular financial reports and approving the annual grant application and budget • Engaging the auditor and accepting the annual audit • Engaging in strategic and operational planning FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 21 www.FTLF.com Governance Requirements • Key authorities (cont.) • Measuring and evaluating the FQHC’s activities • • • • Service utilization patterns Productivity Patient satisfaction Achievement of annual and long-term programmatic and financial goals and objectives (and, as necessary, revising mission, bylaws, goals, objectives, plans and budgets) • Process for hearing and resolving patient grievances • Assuring the FQHC’s compliance with applicable law and regulation FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 22 www.FTLF.com Governance Requirements • HRSA affiliation policies: PIN 97-27 • Corporate Structure • No parent/subsidiary or similar structures (e.g., Sole Member) unless • FQHC retains all Board selection and composition requirements, and exercises all prescribed authorities and • The structure is specifically approved by HRSA FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 23 www.FTLF.com Governance Requirements • PIN 97-27: • 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 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 FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 24 www.FTLF.com Governance Requirements • PIN 97-27 • 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 • Health Services/Clinical Operations • No other entity/individual can employ the majority of FQHC’s primary care providers, subject to good cause exception • Non-exclusivity: no other entity/individual can control FQHC’s relationships with other providers unless control will not impact FQHC’s ability to collaborate and coordinate with other local providers FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 25 www.FTLF.com Core Requirements: Schedule of Discounts • FQHCs must provide services to all residents of the service area regardless of ability to pay • Schedule of charges designed to cover the reasonable costs of operation and consistent with locally prevailing rates • Should not be unreasonably low • “Consistent with” does not mean “equal to” • Corresponding schedule of discounts, adjusted on the basis of ability to pay, for uninsured or underinsured patients: • At 101-200% of poverty guidelines – “slide” fees • At or under 100% poverty – full discount (nominal fee permitted) • Income above 200% of the federal poverty income guidelines NO DISCOUNTS FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 26 www.FTLF.com Payment for Services • FQHCs must make “every reasonable effort” • To secure payments from patients in accordance with fee schedule & schedule of discounts • To collect reimbursement for services provided to persons covered by Medicare, Medicaid, any other public assistance program, or private health insurance, on the basis of full amount of fees and payments without application of any discount FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 27 www.FTLF.com Payment for Services • FQHCs must assure that • No patient will be denied health care services due to an individual’s inability to pay for such services • Any fees or payments required by the FQHC for such services will be reduced or waived to fulfill assurance of access to care • Individualized determinations of financial need FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 28 www.FTLF.com Compliance with 45 CFR Part 74 • Section 330 grantees must comply with the requirements and standards set forth in 45 CFR Part 74 regarding • Financial management systems • 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) FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 29 www.FTLF.com FQHC Benefits • Health Reform: Reimbursement • Expands Medicaid eligibility to cover all nonelderly adults up to 133% of FPL, effective 2014 • 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 FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 30 www.FTLF.com Current Climate • • • Community Health Center Trust Fund: Affordable Care Act included an $11 billion trust fund for health centers • $9.5 billion in operational funding over 5 years (in addition to FQHC discretionary funding) • $1.5 billion to provide enhanced funding for National Health Service Corps Appropriations: FY 2011-2013 Appropriations (for Section 330 grants) • 2011: • Cut discretionary funding from $2.19 billion to $1.59 billion and $1.0 billion was then transferred from the Trust Fund • 2011 funding: $2.59 billion = net increase of $400 million over FY 2010 • 2012: 2011 levels plus $200 million • 2013: Senate Appropriations bill includes $3.1 billion • $1.6 billion in discretionary funding + $1.5 billion in funding from the Trust Fund = $300m increase New Access Point Funding: HRSA made 219 awards on June 20, 2012 FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 31 www.FTLF.com Questions? Jacqueline C. Leifer, Esq. Feldesman Tucker Leifer Fidell LLP 1129 20th Street N.W. – Suite 400 Washington, D.C. 20036 [email protected] www.ftlf.com (202) 466-8960 FELDESMAN TUCKER LEIFER FIDELL LLP © Feldesman Tucker Leifer Fidell LLP. All rights reserved. 32 www.FTLF.com