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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

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 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

5 Benefits Benefit Health Center Grantees FQHC Look-Alikes Grant funding
YES NO Eligible for Medicaid Prospective Payment System (PPS) Eligible for Medicare cost-based reimbursement Access to 340B drug pricing Eligible for Federal Tort Claims Act medical malpractice insurance Automatic Health Professional Shortage Area (HPSA) Designation Vaccines for Children Eligible for supplemental HRSA funding (PCMH, capital investments, HIT incentive payments)

6 Growth of FQHC Look-Alike Program

7 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 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. NO Must 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 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.

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

10 Application Process: Grantee and Look-Alike Comparison
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

11 FQHC Look-Alike Application Types
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.

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 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

14 Application Overview The 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 areas Will maintain or increase access to primary care health services, improve health outcomes, and reduce health disparities 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 Has a collaborative and coordinated delivery system for the provision of health care to the underserved Has a sound and complete plan that is clearly responsive to identified health care needs of the target population Has a reasonable and accurate budget 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

17 Forms and Documents Initial Designation Application Content Type
Cover Page Form Form 1A: General Information Worksheet Table of Contents Document Project Abstract Project Narrative Clinical Performance Measures Financial Performance Measures Form 2: Staffing Profile Form 3: Income Analysis Form Form 3A: FQHC Look-Alike Budget Form 4: Community Characteristics Form 5A: Services Provided Form 5B: Service Sites Form 5C: Other Activities/Locations (if applicable) Form 6A: Current Board Member Characteristics Form 6B: Request for Waiver of Governance Requirements Form 8: Health Center Agreements Form 9: Need for Assistance Form 10: Annual Emergency Preparedness and Management Report Form 12: Contacts Information

18 Attachments Initial Designation Application Content Type
Attachment 1: Patient Origin Study Document Attachment 2: Service Area Map Attachment 3: Current or Requested MUA/MUP Designation Attachment 4: Governing Board Bylaws Attachment 5: Governing Board Meeting Minutes Attachment 6: Co-Applicant Agreement for Public Centers (if applicable) Attachment 7: Affiliation, Contract, and/or Referral Agreements (if applicable) Attachment 8: Articles of Incorporation Attachment 9: Evidence of Non-Profit or Public Agency Status Attachment 10: Medicare and Medicaid Provider Documentation Attachment 11: Organizational Chart Attachment 12: Position Descriptions for Key Personnel Attachment 13: Resumes for Key Personnel Attachment 14: Schedule of Discounts/Sliding Fee Scale Attachment 15: Most Recent Independent Financial Audit Attachment 16: Letters of Support Attachment 17: Floor Plans Attachment 18: Other Information

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. 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 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 GO4-HRSA ( ) or between 9:00 am to 5:30 pm ET or

21 Estimated Timelines 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 Response to any follow-up information requested by HRSA. 30 HRSA review of applicant response to requested follow-up information. 45 CMS CMS review and approval process 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

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

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

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

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

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

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

30 Questions

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

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