Federally Qualified Health Center Look-Alike Program Overview and Initial

Designation Application Process

Jennifer Joseph, PhD, MSEdChief, Strategic Operations Branch

U.S. Department of Health and Human ServicesHealth Resources and Services Administration

Bureau of Primary Health Care

Agenda

• FQHC Definitions, Principles, Benefits and Eligibility

• Program Administration• Application Process• Application Components/Content Overview• Application Submission Information• Review Timelines• Tips for Preparing a Successful Application• Technical Assistance Resources• Questions and Answers

2

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.

3

Fundamental Principles

• Private non-profit or public entities that serve a high-need community or population

• Governed by a community board of which at least a majority are health center patients who represent the patient population served

• Provide comprehensive primary care and enabling and supporting services

• Services are available to all, with fees adjusted based upon ability to pay

• Meet all performance and accountability requirements for administrative, clinical and financial operations

4

Benefits

Benefit Health Center Grantees

FQHC Look-Alikes

Grant funding YES NO

Eligible for Medicaid Prospective Payment System (PPS)

YES YES

Eligible for Medicare cost-based reimbursement

YES YES

Access to 340B drug pricing YES YES

Eligible for Federal Tort Claims Act medical malpractice insurance

YES NO

Automatic Health Professional Shortage Area (HPSA) Designation

YES YES

Vaccines for Children YES YES

Eligible for supplemental HRSA funding (PCMH, capital investments, HIT incentive payments)

YES NO

5

Growth of FQHC Look-Alike Program

1991 20110

20

40

60

80

100

120

28

112

FQHC Look-Alike Organizations

6

Eligibility

Eligibility Requirement Health Center Grantees

FQHC Look-Alikes

Must be a private, charitable, tax-exempt nonprofit organization OR public entity (direct or co-applicant arrangement).

YES YES

Must serve a medically underserved area (MUA) or medically underserved population (MUP) designated by DHHS.

YES YES

Must not be owned, controlled or operated by another entity.

NO YES

Must be operational and providing primary care services at the time of application submission.

NO YES

7

Look-Alike Program Administration

• The FQHC Look-Alike Program is operated under an intra-agency agreement between HRSA and CMS

• HRSA is responsible for:– Assuring compliance with requirements under section

330 of the Public Health Service Act– Making a recommendation to CMS for designation as

a Look-Alike

• CMS is responsible for:– Designating an organization as a Look-Alike– This designation makes the organization eligible to

apply for Medicaid and Medicare reimbursement under the FQHC payment methodologies and to enroll in the 340B drug program.

8

Program Administration

• HRSA staff are responsible for:

– Developing the application instructions

– Providing technical assistance to applicants and existing FQHC Look-Alikes

– Reviewing all initial designation, renewal of designation, and annual certification applications

– Monitoring continued compliance with program requirements

9

Application Process: Grantee and Look-Alike Comparison

Application Health Center Grantees

FQHC Look-Alikes

Application opportunities for new organizations

New Access Point Rolling

HRSA Electronic Handbook (EHB) application and data reporting

YES YES, as of 2011-2012

10

FQHC Look-Alike Application Types

Application Type Description

Initial Designation Comprehensive application required for organizations seeking initial FQHC Look-Alike designation

Renewal of Designation

Comprehensive application required for existing Look-Alike organizations to renew their FQHC Look-Alike designation after an initial two-year designation period, and thereafter, typically every five-years.

Annual Certification An annual program update submitted by existing FQHC Look-Alikes.

11

Initial Designation Application Process

Application submitted

HRSA reviews for completeness and

eligibility

Disapproval

HRSA reviews for compliance

HRSA sends recommendatio

n to CMS

Request for changes and TA

Disapproval

CMS designates organization and

informs HRSA

CMS sends recommendation to CMS regional office and State Medicaid

agency

HRSA sends Notice of Look-

Alike Designation

Newly designated FQHC Look-Alike applies to CMS and State Medicaid

agency for FQHC Medicare and Medicaid numbers

Enrolling for FQHC Medicare and Medicaid Reimbursement

• FQHC Look-Alike designation establishes eligibility to enroll in Medicare as an FQHC and for enrollment in State Medicaid program as an FQHC provider.

• Each organization must:

– Prepare and submit a Medicare Enrollment application for each permanent and seasonal site and ensure that it has received the appropriate approvals prior to billing under the FQHC benefit

– Enroll in their State Medicaid program as an FQHC provider 13

Application Overview

The Initial Designation application demonstrates compliance with the requirements of section 330 of the PHS Act, including evidence that the organization:

1. Serves populations in high-need areas

2. Will maintain or increase access to primary care health services, improve health outcomes, and reduce health disparities

3. Provides ready access to the full range of required primary, preventive, enabling and supplemental health care services to all persons in the target population

Application Overview

4. Has a collaborative and coordinated delivery system for the provision of health care to the underserved

5. Has a sound and complete plan that is clearly responsive to identified health care needs of the target population

6. Has a reasonable and accurate budget

7. Is already operational and providing primary, preventive, enabling and supplemental services in the community

Application Components

• Program Narrative– Need– Response – Collaboration– Evaluative measures– Resources/capabilities– Governance

• Forms and Documents

• Attachments

16

Forms and Documents

Initial Designation Application Content Type

Cover Page Form

Form 1A: General Information Worksheet Form

Table of Contents Document

Project Abstract Document

Project Narrative Document

Clinical Performance Measures Form

Financial Performance Measures Form

Form 2: Staffing Profile Form

Form 3: Income Analysis Form Document

Form 3A: FQHC Look-Alike Budget Form

Form 4: Community Characteristics Form

Form 5A: Services Provided Form

Form 5B: Service Sites Form

Form 5C: Other Activities/Locations (if applicable) Form

Form 6A: Current Board Member Characteristics Form

Form 6B: Request for Waiver of Governance Requirements Form

Form 8: Health Center Agreements Form

Form 9: Need for Assistance Form

Form 10: Annual Emergency Preparedness and Management Report Form

Form 12: Contacts Information Form

Attachments

Initial Designation Application Content Type

Attachment 1: Patient Origin Study Document

Attachment 2: Service Area Map Document

Attachment 3: Current or Requested MUA/MUP Designation Document

Attachment 4: Governing Board Bylaws Document

Attachment 5: Governing Board Meeting Minutes Document

Attachment 6: Co-Applicant Agreement for Public Centers (if applicable) Document

Attachment 7: Affiliation, Contract, and/or Referral Agreements (if applicable) Document

Attachment 8: Articles of Incorporation Document

Attachment 9: Evidence of Non-Profit or Public Agency Status Document

Attachment 10: Medicare and Medicaid Provider Documentation Document

Attachment 11: Organizational Chart Document

Attachment 12: Position Descriptions for Key Personnel Document

Attachment 13: Resumes for Key Personnel Document

Attachment 14: Schedule of Discounts/Sliding Fee Scale Document

Attachment 15: Most Recent Independent Financial Audit Document

Attachment 16: Letters of Support Document

Attachment 17: Floor Plans Document

Attachment 18: Other Information Document

Application Submission

• Applications must be submitted through the HRSA EHB

– Refer to HRSA’s Electronic Submission User Guide, available online at http://bphc.hrsa.gov/about/lookalike/index.html for detailed application and submission instructions.

• Once the Initial Designation application process is started in the EHB system, it must be completed and submitted in a maximum of 90 calendar days.

• Applications that are ineligible or not completed within 90 days will not be considered for designation. 19

Registering in the EHB

• Step one: Create individual system accounts for each individual who will assist in the application preparation, including the following roles: Authorizing official (AO); Business official (BO); Other employee (project directors, assistant staff)

• Step two: Associate individuals with the appropriate organization.

• For assistance in registering with HRSA EHBs, call 877-GO4-HRSA (877-464-4772) or 301-998-7373 between 9:00 am to 5:30 pm ET or email callcenter@hrsa.gov

20

Estimated Timelines

21

Responsible Entity

Step in Process Number of Days

Applicant Development and submission of application once the application process has been initiated in the EHB.

90

HRSA Initial review of the application once received in EHB.

105

Applicant Response to any follow-up information requested by HRSA.

30

HRSA HRSA review of applicant response to requested follow-up information.

45

CMS CMS review and approval process 30

Estimated time from application submission to CMS approval for an application with no follow-up information requested by HRSA: Up to 135 days

Estimated time from application submission to CMS approval for an application requiring follow-up information: Up to 210 days

Preparing for a Successful Application

• Perform a thorough needs assessment early

• Request technical assistance from your PCA/PCO or other experienced health centers

• Ensure that the organization is operating in full compliance with each program requirement, including active involvement and oversight of a governing board

• Ensure that all application forms, attachments, and program narrative provide consistent information

• Take advantage of technical assistance resources

Avoiding Common Mistakes

Common mistakes in applications:

• Organization did not meet the eligibility requirements

• Organization did not demonstrate compliance with all program requirements

• Inconsistencies between the program narrative and data forms

• Application did not include all required forms and attachments

• Applicant did not correctly complete required forms

23

Avoiding Common Mistakes: Eligibility

• Organization was owned, operated, or controlled by another entity

• Organization did not have non-profit status

• Organization was not serving, in whole or in part, a MUA/MUP

24

Avoiding Common Mistakes: Need

• Organization’s service area was not clearly defined

• Service area overlap existed with an existing FQHC

• Application contained no discussion of other providers or did not include letters of support from other providers (or an explanation for why they were not included)

• Application data tables did not align with the program narrative and/or organizational chart

25

Avoiding Common Mistakes: Health Services

• Organization did not have after-hours coverage

• Organization did not have a sliding fee scale or the sliding fee scale was not based on the most recent FPL

• Organization did not have admitting privileges or document a continuity of care plan, including discharge planning

26

Avoiding Common Mistakes: Management and Finance

• Organization did not comprehensively discuss lines of authority

• Organization’s organizational chart lacked the names and FTEs of staff or was not aligned with the narrative

• Application did not contain a recent audit

• Organization did not have Medicare and Medicaid provider numbers by site to demonstrate its operational status

27

Avoiding Common Mistakes: Governance

• Organization’s governing board had non-compliant bylaws

• Public entity organization’s co-applicant agreement was not clearly written

• Governing board bylaws did not contain a conflict of interest policy

• The governing board included employees of the organization

• The governing board did not meet at least monthly

28

Key Resources for Application Development

• FQHC Look-Alike Application Instructions 2011-2012 and EHB System User Guides: http://bphc.hrsa.gov/about/lookalike/index.html

• Service Area Overlap: Policy and Process (PIN 2007-09) for guidance on preparing a service area overlap analysis

• Health Center Program Requirements: http://bphc.hrsa.gov/about/requirements/index.html

• FQHC Look-Alike Application Resources document under “Application Help” on the TA page

29

Questions

30

Contact Information

Jennifer JosephChief, Strategic Operations Branch

Telephone: 301-594-4300E-mail: FQHCLAL@hrsa.gov

31