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Federally Qualified Health Center Look-Alike Program Overview and Initial Designation Application Process Jennifer Joseph, PhD, MSEd Chief, Strategic Operations.

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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 Process Jennifer Joseph, PhD, MSEd Chief, Strategic Operations Branch U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care

2 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

3 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

4 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

5 Benefits BenefitHealth Center Grantees FQHC Look- Alikes Grant fundingYESNO Eligible for Medicaid Prospective Payment System (PPS) YES Eligible for Medicare cost-based reimbursement YES Access to 340B drug pricingYES Eligible for Federal Tort Claims Act medical malpractice insurance YESNO Automatic Health Professional Shortage Area (HPSA) Designation YES Vaccines for ChildrenYES Eligible for supplemental HRSA funding (PCMH, capital investments, HIT incentive payments) YESNO 5

6 Growth of FQHC Look-Alike Program 6

7 Eligibility Eligibility RequirementHealth Center Grantees FQHC Look- Alikes Must be a private, charitable, tax-exempt nonprofit organization OR public entity (direct or co-applicant arrangement). YES Must serve a medically underserved area (MUA) or medically underserved population (MUP) designated by DHHS. YES Must not be owned, controlled or operated by another entity. NOYES Must be operational and providing primary care services at the time of application submission. NOYES 7

8 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

9 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

10 Application Process: Grantee and Look- Alike Comparison ApplicationHealth Center Grantees FQHC Look-Alikes Application opportunities for new organizations New Access PointRolling HRSA Electronic Handbook (EHB) application and data reporting YESYES, as of

11 FQHC Look-Alike Application Types Application TypeDescription Initial DesignationComprehensive application required for organizations seeking initial FQHC Look-Alike designation Renewal 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. 11

12 Initial Designation Application Process Application submitted HRSA reviews for completeness and eligibility Disapproval HRSA reviews for compliance HRSA sends recommendation 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

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

14 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

15 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

16 Application Components Program Narrative –Need –Response –Collaboration –Evaluative measures –Resources/capabilities –Governance Forms and Documents Attachments 16

17 Forms and Documents Initial Designation Application ContentType 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

18 Attachments Initial Designation Application ContentType 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

19 Application Submission Applications must be submitted through the HRSA EHB –Refer to HRSA’s Electronic Submission User Guide, available online at for detailed application and submission instructions.http://bphc.hrsa.gov/about/lookalike/index.html 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

20 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 ( ) or between 9:00 am to 5:30 pm ET or 20

21 Estimated Timelines 21 Responsible Entity Step in ProcessNumber of Days ApplicantDevelopment and submission of application once the application process has been initiated in the EHB. 90 HRSAInitial review of the application once received in EHB.105 ApplicantResponse to any follow-up information requested by HRSA. 30 HRSAHRSA review of applicant response to requested follow-up information. 45 CMSCMS review and approval process30 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

22 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

23 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

24 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

25 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

26 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

27 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

28 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

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 analysis Health Center Program Requirements: FQHC Look-Alike Application Resources document under “Application Help” on the TA page 29

30 Questions 30

31 Contact Information Jennifer Joseph Chief, Strategic Operations Branch Telephone:


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