Presentation on theme: "Federally Qualified Health Center Look-Alike Program Overview and Initial Designation Application Process Jennifer Joseph, PhD, MSEd Chief, Strategic Operations."— Presentation transcript:
1 Federally Qualified Health Center Look-Alike Program Overview and Initial Designation Application ProcessJennifer Joseph, PhD, MSEdChief, Strategic Operations BranchU.S. Department of Health and Human ServicesHealth Resources and Services AdministrationBureau of Primary Health Care
2 Agenda FQHC Definitions, Principles, Benefits and Eligibility Program AdministrationApplication ProcessApplication Components/Content OverviewApplication Submission InformationReview TimelinesTips for Preparing a Successful ApplicationTechnical Assistance ResourcesQuestions and Answers
3 Respectively, Social Security Act §1861(aa)(4) and §1905(l)(2)(B) 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.
4 Fundamental Principles Private non-profit or public entities that serve a high- need community or populationGoverned by a community board of which at least a majority are health center patients who represent the patient population servedProvide comprehensive primary care and enabling and supporting servicesServices are available to all, with fees adjusted based upon ability to payMeet all performance and accountability requirements for administrative, clinical and financial operations
5 Benefits Benefit Health Center Grantees FQHC Look-Alikes Grant funding YESNOEligible for Medicaid Prospective Payment System (PPS)Eligible for Medicare cost-based reimbursementAccess to 340B drug pricingEligible for Federal Tort Claims Act medical malpractice insuranceAutomatic Health Professional Shortage Area (HPSA) DesignationVaccines for ChildrenEligible for supplemental HRSA funding (PCMH, capital investments, HIT incentive payments)
7 Eligibility Eligibility Requirement Health Center Grantees FQHC Look-AlikesMust be a private, charitable, tax-exempt nonprofit organization OR public entity (direct or co-applicant arrangement).YESMust serve a medically underserved area (MUA) or medically underserved population (MUP) designated by DHHS.Must not be owned, controlled or operated by another entity.NOMust be operational and providing primary care services at the time of application submission.
8 Look-Alike Program Administration The FQHC Look-Alike Program is operated under an intra-agency agreement between HRSA and CMSHRSA is responsible for:Assuring compliance with requirements under section 330 of the Public Health Service ActMaking a recommendation to CMS for designation as a Look-AlikeCMS is responsible for:Designating an organization as a Look-AlikeThis 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.
9 Program Administration HRSA staff are responsible for:Developing the application instructionsProviding technical assistance to applicants and existing FQHC Look-AlikesReviewing all initial designation, renewal of designation, and annual certification applicationsMonitoring continued compliance with program requirements
10 Application Process: Grantee and Look-Alike Comparison Health Center GranteesFQHC Look-AlikesApplication opportunities for new organizationsNew Access PointRollingHRSA Electronic Handbook (EHB) application and data reportingYESYES, as of
11 FQHC Look-Alike Application Types DescriptionInitial DesignationComprehensive application required for organizations seeking initial FQHC Look-Alike designationRenewal of DesignationComprehensive 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 CertificationAn annual program update submitted by existing FQHC Look-Alikes.
12 Initial Designation Application Process Application submittedHRSA reviews for completeness and eligibilityDisapprovalHRSA reviews for complianceHRSA sends recommendation to CMSRequest for changes and TACMS designates organization and informs HRSACMS sends recommendation to CMS regional office and State Medicaid agencyHRSA sends Notice of Look-Alike DesignationNewly designated FQHC Look-Alike applies to CMS and State Medicaid agency for FQHC Medicare and Medicaid numbers
13 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 benefitEnroll in their State Medicaid program as an FQHC provider
14 Application OverviewThe Initial Designation application demonstrates compliance with the requirements of section 330 of the PHS Act, including evidence that the organization:Serves populations in high-need areasWill maintain or increase access to primary care health services, improve health outcomes, and reduce health disparitiesProvides ready access to the full range of required primary, preventive, enabling and supplemental health care services to all persons in the target population
15 Application OverviewHas a collaborative and coordinated delivery system for the provision of health care to the underservedHas a sound and complete plan that is clearly responsive to identified health care needs of the target populationHas a reasonable and accurate budgetIs already operational and providing primary, preventive, enabling and supplemental services in the community
16 Application Components Program NarrativeNeedResponseCollaborationEvaluative measuresResources/capabilitiesGovernanceForms and DocumentsAttachments
17 Forms and Documents Initial Designation Application Content Type Cover PageFormForm 1A: General Information WorksheetTable of ContentsDocumentProject AbstractProject NarrativeClinical Performance MeasuresFinancial Performance MeasuresForm 2: Staffing ProfileForm 3: Income Analysis FormForm 3A: FQHC Look-Alike BudgetForm 4: Community CharacteristicsForm 5A: Services ProvidedForm 5B: Service SitesForm 5C: Other Activities/Locations (if applicable)Form 6A: Current Board Member CharacteristicsForm 6B: Request for Waiver of Governance RequirementsForm 8: Health Center AgreementsForm 9: Need for AssistanceForm 10: Annual Emergency Preparedness and Management ReportForm 12: Contacts Information
18 Attachments Initial Designation Application Content Type Attachment 1: Patient Origin StudyDocumentAttachment 2: Service Area MapAttachment 3: Current or Requested MUA/MUP DesignationAttachment 4: Governing Board BylawsAttachment 5: Governing Board Meeting MinutesAttachment 6: Co-Applicant Agreement for Public Centers (if applicable)Attachment 7: Affiliation, Contract, and/or Referral Agreements (if applicable)Attachment 8: Articles of IncorporationAttachment 9: Evidence of Non-Profit or Public Agency StatusAttachment 10: Medicare and Medicaid Provider DocumentationAttachment 11: Organizational ChartAttachment 12: Position Descriptions for Key PersonnelAttachment 13: Resumes for Key PersonnelAttachment 14: Schedule of Discounts/Sliding Fee ScaleAttachment 15: Most Recent Independent Financial AuditAttachment 16: Letters of SupportAttachment 17: Floor PlansAttachment 18: Other Information
19 Application Submission Applications must be submitted through the HRSA EHBRefer to HRSA’s Electronic Submission User Guide, available online at 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.
20 Registering in the EHBStep 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 GO4-HRSA ( ) or between 9:00 am to 5:30 pm ET or
21 Estimated Timelines Responsible Entity Step in Process Number of Days ApplicantDevelopment and submission of application once the application process has been initiated in the EHB.90HRSAInitial review of the application once received in EHB.105Response to any follow-up information requested by HRSA.30HRSA review of applicant response to requested follow-up information.45CMSCMS review and approval processEstimated time from application submission to CMS approval for an application with no follow-up information requested by HRSA: Up to 135 daysEstimated time from application submission to CMS approval for an application requiring follow-up information: Up to 210 days
22 Preparing for a Successful Application Perform a thorough needs assessment earlyRequest technical assistance from your PCA/PCO or other experienced health centersEnsure that the organization is operating in full compliance with each program requirement, including active involvement and oversight of a governing boardEnsure that all application forms, attachments, and program narrative provide consistent informationTake advantage of technical assistance resources
23 Avoiding Common Mistakes Common mistakes in applications:Organization did not meet the eligibility requirementsOrganization did not demonstrate compliance with all program requirementsInconsistencies between the program narrative and data formsApplication did not include all required forms and attachmentsApplicant did not correctly complete required forms
24 Avoiding Common Mistakes: Eligibility Organization was owned, operated, or controlled by another entityOrganization did not have non-profit statusOrganization was not serving, in whole or in part, a MUA/MUP
25 Avoiding Common Mistakes: Need Organization’s service area was not clearly definedService area overlap existed with an existing FQHCApplication 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
26 Avoiding Common Mistakes: Health Services Organization did not have after-hours coverageOrganization did not have a sliding fee scale or the sliding fee scale was not based on the most recent FPLOrganization did not have admitting privileges or document a continuity of care plan, including discharge planning
27 Avoiding Common Mistakes: Management and Finance Organization did not comprehensively discuss lines of authorityOrganization’s organizational chart lacked the names and FTEs of staff or was not aligned with the narrativeApplication did not contain a recent auditOrganization did not have Medicare and Medicaid provider numbers by site to demonstrate its operational status
28 Avoiding Common Mistakes: Governance Organization’s governing board had non-compliant bylawsPublic entity organization’s co-applicant agreement was not clearly writtenGoverning board bylaws did not contain a conflict of interest policyThe governing board included employees of the organizationThe governing board did not meet at least monthly
29 Key Resources for Application Development FQHC Look-Alike Application Instructions and EHB System User Guides:Service Area Overlap: Policy and Process (PIN ) for guidance on preparing a service area overlap analysisHealth Center Program Requirements:FQHC Look-Alike Application Resources document under “Application Help” on the TA page