June 23, 2008 1

The Federally Qualified Health Center Look-Alike Program:

Past, Present, and Future

Tonya Bowers, Interim DirectorTwyla Adams, Branch Chief

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

Bureau of Primary Health Care

Health Resources and Services Administration2008 Primary Health Care All-Grantee Meeting

June 23, 2008 2

Workshop Objectives

This workshop will: Cover the basics of the FQHC Look-Alike

Program. Exam the recent trends under the

FQHC Look-Alike Program. Present the challenges and

opportunities for the FQHC Look-Alike Program.

June 23, 2008 3

Basics of the FQHC Look-Alike Program

June 23, 2008 4

Background

Medicare and Medicaid statutes define the provider type “Federally Qualified Health Center” (FQHC):

Social Security Act §1861(aa)(4) and §1905(l)(2)(B) respectively.

June 23, 2008 5

Definition of an FQHC An entity that receives a grant under section 330

of the Public Health Service Act (PHSA) – Health Center Program:

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).

An entity that is determined by DHHS to meet requirements to receive funding without actually receiving a grant (i.e., requirements for an FQHC “Look-Alike” entity are found in PINs #2003-21 & #2005-17).

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FQHC Look-Alike Eligibility Requirements

Must be 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.

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

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

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Benefits of FQHC Look-Alike Status

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.

Have access to favorable drug pricing under Section 340B of the PHSA.

Have the right to have “outstationed” Medicaid eligibility workers.

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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.

Reimbursement by Medicare for "first dollar" of services rendered to beneficiaries, i.e., deductible is waived.

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 and eligibility to participate in the Pfizer Sharing the Care Program.

Benefits of FQHC Look-Alike Status

June 23, 2008 9

FQHC 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 PHSA.

Making a recommendation to CMS for designation as an FQHC Look-Alike.

CMS has final authority to designate applicants as an FQHC Look-Alike.

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FQHC Look-Alike Program Administration

HRSA staff are responsible for: Developing the application guidance. Providing technical assistance to

applicants and existing FQHC Look-Alikes. Reviewing applications. Coordinating site visits. Monitoring continued compliance.

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Recent Trends under the FQHC Look-Alike Program

June 23, 2008 12

FQHC Look-Alike Project Officers

Twyla Adams (301-594-4439) Branch Chief

Cristina Petruccelli (301-594-4118) CT, ME, NH, RI, VT, AL, FL, GA, KY, MS, NC, SC, TN

Cicely Nelson (301-594-4496) AR, LA, NM, OK, TX

Blanca Fuertes (301-443-0612) and Michelle Parker (301-594-4285)

OH, MI, WI, MN, IL, IN, MO, IA, NE, KS Valerie Bowers (301-443-7364)

NY, NJ, MD, WV, VA, SD, ND, CO, MT, UT, ID, WA, OR, WY, PR, DE, PA, DC, AR

Bette Darling (301-594-4342) CA, NV, AZ, HI

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28

111 112

90

107

124 121 122

0

20

40

60

80

100

120

140

1991 2001 2002 2003 2004 2005 2006 2007

FQHC Look-Alike Program Growth 1991-2007

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25

39

21

39

17 17

8

21

0

5

10

15

20

25

30

35

40

45

2004 2005 2006 2007

Applications Received

Designations

Number of Applications and New Designations 2004-2007

June 23, 2008 15

Trend Revenue Per Payor Type

6% 7% 6% 9% 7%

32%39%

27%

40%34%

13%

13%

17%

13%19%

23% 9% 23%

19% 25%

25%32% 27%

19% 14%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 2004 2005 2006 2007

Medicare Medicaid Other Public Payer Third Party Self Pay

June 23, 2008 16

Success Rates for NAP Funding2002-2007

Of the FQHC Look-Alikes that applied for NAP new start funding:

FY 2002: 43% (24/56) were successful.

FY 2003: 33% (17/51) were successful.

FY 2004: 7% (4/58) were successful.

FY 2005: 33% (12/36) were successful.

FY 2006: 59% (22/37) were successful.

FY 2007: 48% (23/48) were successful.

June 23, 2008 17

Success Rates for NAP Funding2002-2007

Of the organizations that received NAP new start grants:

FY 2002: 27% (24/88) were FQHC Look-Alikes.

FY 2003: 32% (17/53) were FQHC Look-Alikes.

FY 2004: 15% (4/27) were FQHC Look-Alikes.

FY 2005: 28% (12/45) were FQHC Look-Alikes.

FY 2006: 40% (22/55) were FQHC Look-Alikes.

FY 2007: 47% (23/49) were FQHC Look-Alikes.

June 23, 2008 18

Challenges and Opportunities for the FQHC Look-Alike

Program

June 23, 2008 19

Challenges

Challenge #1: Reviewing initial submissions of FQHC Look-Alike new designation applications in which 90-95% are non-compliant.

Challenge #2: Having partners who are not knowledgeable about the FQHC Look-Alike Program.

Challenge #3: Streamlining data collection for increased program analysis.

June 23, 2008 20

Opportunities:Assure Compliance

Revise the FQHC Look-Alike application guidance.

The goals of the revised guidance are to: Enhance clarity in conveying HRSA’s

expectations to applicants. Better align FQHC Look-Alike

application requirements to those in the section 330 grant program.

June 23, 2008 21

Opportunities:Assure Compliance

Proposed revisions to the existing application guidance include: Creation of designation periods up to 5 years. Adoption of application forms used in the

section 330 grant applications. Submission of 5-year health care and business

plans. Allowance of governance waivers for

organizations that serve special populations as defined in section 330 of the PHSA.

June 23, 2008 22

Opportunities:Assure Compliance

Status of revised application guidance:

Draft guidance was released for a 60-day public comment in the fall of 2007.

Draft guidance will be released for a second 60-day public comment in the summer of 2008 as a result of the comments received and resulting changes.

HRSA projects releasing the revised application guidance in final in the fall of 2008.

June 23, 2008 23

Opportunities:Assure Compliance

Conduct compliance site visits to verify compliance with requirements under section 330 of the PHSA.

Description of compliance site visits:

10 pre-designation and 10 post-designation compliance site visits will be conducted in FY 2008.

An organization may receive a compliance site visit if its paper application for new designation or recertification is approvable.

To ensure diversity, selection factors will include geographic region, urban/rural, private/public, and single site/multiple sites.

If areas of non-compliance are identified during the site visit, HRSA will provide the organization with technical assistance in order to come into compliance.

June 23, 2008 24

Opportunities:Assure Compliance

Status of the compliance site visits: HRSA will disseminate a Program

Assistance Letter that provides more specific information about the compliance site visits in the summer of 2008.

HRSA will implement the compliance site visits in the summer of 2008.

June 23, 2008 25

Opportunities:Strengthen Partnerships

Develop and strengthen relationships with partners to increase their knowledge and understanding of the FQHC Look-Alike Program by: Convening brown bag sessions for HRSA

staff. Defining roles for partners. Developing additional educational

materials. Convening national conference calls.

June 23, 2008 26

Opportunities:Streamline Data Collection

HRSA anticipates integrating the FQHC Look-Alike Program into the HRSA-wide EHB System in 2009.

At that time, new applicants and existing FQHC Look-Alikes will be able to submit applications electronically.

It will facilitate data extraction in order to analyze data trends.

June 23, 2008 27

Questions?

June 23, 2008 28

Tonya BowersInterim Director

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

Bureau of Primary Health Care5600 Fishers Lane Room 17C-26

Rockville, MD 20857Telephone: 301.594.4300

Fax: 301.594-4984E-mail: Tonya.Bowers@hrsa.hhs.gov

Contact Information

June 23, 2008 29

Twyla AdamsBranch Chief

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

Bureau of Primary Health Care5600 Fishers Lane Room 17C-26

Rockville, MD 20857Telephone: 301.594.4300

Fax: 301.480.7225E-mail: Twyla.Adams@hrsa.hhs.gov

Contact Information