Federally Qualified Health Center Look-Alike Program Overview and Initial Designation Application Process

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. 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

6. Growth of FQHC Look-Alike Program

7. Eligibility

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

11. FQHC Look-Alike Application Types

12. Initial Designation Application Process Request for changes and TA Disapproval Disapproval HRSA reviews for completeness and eligibility Application submitted HRSA reviews for compliance CMS sends recommendation to CMS regional office and State Medicaid agency CMS designates organization and informs HRSA HRSA sends recommendation to CMS Newly designated FQHC Look-Alike applies to CMS and State Medicaid agency for FQHC Medicare and Medicaid numbers HRSA sends Notice of Look-Alike Designation

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

18. Attachments

19. 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.

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 (877-464-4772) or 301-998-7373 between 9:00 am to 5:30 pm ET or email callcenter@hrsa.gov

21. Estimated Timelines 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 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

30. Questions

31. Contact Information Jennifer Joseph Chief, Strategic Operations Branch Telephone: 301-594-4300 E-mail: FQHCLAL@hrsa.gov