ISSUE

TABLES AFFECTED

TREATMENT

Contracted Care (Specialty, dental,

mental health, etc.)

(Service must be paid for by grantee!)

5

Providers (Column A) are counted if the contract is for a portion of an FTE (e.g., one day a week OB = 0.20 FTE).  Providers are not counted if contract is for a service (e.g., $X per visit or $55 per RBRVU).    Encounters (Column B) are always counted, regardless of method of provider payment or location of service (grantee's site or contract provider's office.) 

6

Grantee receives encounter form or equivalent from contract provider, counts primary diagnosis and/or services provided as applicable.

8A

Column A:  Net Cost.      Cost of provider/service is reported on applicable line.

Column B:  Overhead.       Grantee will generally use a lower "overhead rate" for off-site services.

9D

Charge (Column A) is grantee's UCR charge if on-site; as contractor's UCR charge if off site.     

Collection (Column B) is the amount received by either grantee or contractor from first or third parties.     

Allowance (column D) is amount disallowed by a third party for the charge (if on lines 1 - 12)     

Sliding Discount (column E) is amount written off if the patient is uninsured (line 13).  Calculated as UCR charge minus amount collected from patient, minus amount owed by patient as their share of payment.

Services provided by a volunteer provider (Service are not paid for by grantee!)

5

Providers (Column A) are counted if the service is provided on site at grantees clinic.  Hours volunteered are used to calculate FTE as with any other part time provider.  Providers are not counted if their services are provided at their own offices.   

Encounters (Column B) are counted only if the service is provided at the site in the contractors scope of service and under the grantee's control.

6

Grantee counts primary diagnosis and/or services provided on site, as applicable.

9D

If on-site, treated exactly the same as for staff.  Do not include if off-site.

WIC

Cover Sheets

Do not list WIC-only sites on the cover pages.

3A, 3B, 4

Clients whose only contact with the grantee is for WIC services and who do not receive another form of service counted on Table 5 from providers outside of the WIC program are not counted as patients on any of these tables.   Do not count as patients because of health education or enabling services provided by WIC.

5

Staff (Column A) are counted on line 29a. 

Encounters and patients (Columns B and C) are never reported unless otherwise justified.

8A

Column A:  Net costs.       Total cost of program reported in column a.

Column B:  Overhead.       Since much of the administrative cost of the program will be included in the direct costs, it is presumed that overhead will be at a significantly lower rate.

9D

Nothing associated with the WIC program is to be reported on this table.

9E

Income for WIC programs, though originally federal, comes to grantees from the State.  Unless the grantee is a state government, the grant/contract funds received are reported on line 6.

In-house pharmacy or dispensary services for grantee's patients [see below for other situations].

(including only that part of pharmacy that is paid for by the grantee and dispensed by in-house staff.)

5

Column A:  Staff.      Pharmacy staff are normally reported on line 23.  To the extent that the pharmacy staff have an incidental responsibility to provide assistance in enrolling patients in Pharmaceutical Assistance Programs, they are included on line 23.  Staff (generally not including pharmacists) who spend a readily identifiable portion of their time with PAP programs should be counted on line 28, the "other enabling" line.

Column B:  Encounters.       The UDS does not require the counting or reporting of encounters with pharmacy whether it is for filling prescriptions or associated education or other patient / provider support.

8A

Line 8b, Column A:  Pharmaceutical Direct Costs.      The actual cost of drugs purchased by the pharmacy is placed on line 8b.  (The value of donated drugs (generally calculated at 340(b) rates) is reported on line 18 in column c.) 

Line 8a, column A:  Other Pharmacy Direct Costs.      All other operating costs of the pharmacy are shown on line 8a.  Include salaries, benefits, pharmacy computers, supplies, etc.  

Line 11, column A:  Enabling Direct Costs.      Show the staff and other costs of staff (full- time, part-time or allocated time) spent assisting patients to become eligible for PAPs.

Column B:  Facility and Administration.       All overhead costs associated with line 8a and 8b are reported on line 8a.  While there may be some overhead cost associated with the actual purchase of the drugs, these costs are generally minimal when compared to the total cost of the drugs.

8B

Line 11:  Eligibility Services.       The cost of helping gain eligibility for PAPs is shown on line 11.

9D

Charge (Column A) is grantee's full retail charge for the drugs dispensed. 

Collection (Column B) is the amount received from patients or insurance companies.     

Allowance (column D) is amount disallowed by a third party for the charge (if on lines 1 - 12)     

Sliding Discount (column E) is amount written off if the patient is uninsured (line 13).  Calculated as retail charge minus amount collected from patient, minus amount owed by patient as their share of payment.

9E

The value of donated drugs is not reported on this table - it is reported on Table 8A.  (See above)

In-house pharmacy for community

(i.e., for non-patients)

description

Many CHCs which own licensed pharmacies which also provide services to members of the community at large who are not CHC patients.  Careful records are required to be kept at these pharmacies to ensure that drugs purchased under section 340(b) provisions are not dispensed to patients.  Some of these pharmacies are totally in-scope, while others have their "public" portion out of scope.  If the public aspect is "out of scope", none of its activities are reported on the UDS.  If it is in scope, the public portion should be considered an "other activity" and treated as follows:

5

Column A:  Staff.       Report allocated public portion of staff on line 29a:  Other Programs and Services.

8A

Report all related costs, including cost of pharmaceuticals, on line 12:  Other Related Services.

9E

Report all income from public pharmacy on line 10:  Other, and specify that it is from "Public Pharmacy."

Contract Pharmacy

Dispensing to clinic patients, generally using 340(b) purchased drugs

5

No staff, encounters or patients are reported.  PAP staff all go to enabling services.

8A

If the pharmacy is charging one amount for "managing" the program and/or an amount for "dispensing" the drugs; and another amount for the drugs themselves, the former charge is reported on line 8a, the latter on line 8b.

If the CHC is purchasing the drugs directly [because of 340(b) regulations] the amount it spends on purchasing goes on line 8b, and any administrative or dispensing costs charged by the pharmacy go on line 8a.

If the pharmacy is reporting a flat amount for services including both pharmaceuticals and their services, and there is no reasonable way to separate the amounts report all costs on line 8b.  Associated administrative costs will go on line 8a in column B, even though line 8a column A is blank.

If prepackaged drugs are being purchased, and there is no reasonable way to separate the pharmaceutical costs from the dispensing / administrative costs report all costs on line 8b.  Associated administrative costs will go on line 8a in column B, even though line 8a column A is blank.

9D

Charge (Column A) is grantee's full retail charge for the drugs dispensed or the amount charged by the pharmacy / pre-packager if retail is not known.

Collection (Column B) is the amount received from patients or insurance companies or, under certain circumstances, the pharmacy.  (Note:  most CHCs have this arrangement only for their uninsured patients.)

Allowance (column D) is amount disallowed by a third party for the charge (if on lines 1 - 12)     

Sliding Discount (column E) is amount written off if the patient is uninsured (line 13).  Calculated as retail charge (or pharmacy charge) minus amount collected from patient (by pharmacy or CHC), minus amount owed by patient as their share of payment.

9E

No income would be reported on Table 9E.

Donated Drugs

8A

If the drugs are donated to the CHC and then dispensed to patients show their value [generally calculated at 340(b) rates] on line 18, column C.       If the drugs are donated directly to the patient no accounting for the value of the drugs is made in the UDS, even if the CHC receives and holds the drugs for the patient.

9D

If a dispensing fee is charged to the patient, show this amount (only) and its collection / write-off.

9E

Do not show any amount, even though GAAP might suggest another treatment for the value.

Clinical dispensing of drugs

description

Many pharmaceuticals, ranging from vaccines to allergy shots to family planning shots or pills, are dispensed in the clinic area of the CHC.  This dispensing is considered to be a service attendant to the visit where it was ordered or, in the case of vaccinations, to be a community service.  In most instances it is appropriate to charge for these services, though they are not considered to be encounters.

3A/3B/4

If this is the only service the individual has received during the year, they are not counted as patients.

5

These services are not counted as separate visits.

6

Because these are not visits, they are not counted on Table 6.

8A

Costs are reported on line 8b - pharmaceuticals.  In the case of vaccines obtained at no cost through the Vaccines For Children program, the value may be reported on line 18 - donated services and supplies.

9D

Full charges, collections, allowances and discounts are reported as appropriate.  Note that it is not appropriate to charge for a pharmaceutical that has been donated, though an administration and/or dispensing fee is appropriate.  Note that Medicare has separate flu vaccine rules.

9E

Do not show any amount, even though GAAP might suggest another treatment for the value.

Adult Day Health Care (ADHC)

description

ADHC programs are recognized by Medicare, Medicaid and certain other third party payors.  They involve caring for an infirm, frail elderly patient during the day to permit family members to work, and to avoid the institutionalization of and preserve the health of the patient.  They are quite expensive and may involve extraordinary PMPM capitation payments, though are thought to be cost effective compared to institutionalization.  If patients are covered by both Medicare and Medicaid treat as in Medi-Medi, below.

5

When a provider does a formal, separately billable, examination of a patient at the ADHC facility, it is treated as any other medical visit.  The nursing, observation, monitoring, and dispensing of medication services which are bundled together to form an ADHC service are not counted as a visit for the purposes of reporting on this table.

9D

ADHC charges and collections are reported.  Because of Medicaid FQHC procedures it is possible that there will also be significant positive or negative allowances.  See also Medi-Medi below.

Medi-Medi Cross-Over

description

Some individuals are eligible for both Medicare and Medicaid coverage.  In this case, Medicare is primary and billed first.  After Medicare pays its (usually FQHC) fee, the remainder is billed to Medicaid which pays the difference between its FQHC rate and what Medicare paid.

4

Patients are reported on line 9, Medicare.  Do not report as Medicaid!

9D

While initially the entire charge shows as a Medicare charge, after Medicare makes its payment, the remaining amount is re-classified to Medicaid.  This means that eventually the charges and collections will be the same, though for any given twelve month period the cash positions will probably not net out.  In most cases a large portion of the total charge will transfer to Medicaid where it will be received and/or written off as an allowance.

Certain grant supported clinical care programs:  BCCCP, Title X, etc.

(These are fee-for service or fee-per-visit programs only.)

description

Some programs pay providers on a fee-for-service or fee-per visit basis under a contract which may or may not also have a cap on total payments per year.  They cover a very narrow range of services.  Breast and Cervical Cancer Control and Family Planning programs are the most common, but there are others.

4

These are not insurance programs.  They pay for a service, but the patient is to be classified according to their primary health insurance carrier.  Most of these programs do not serve insured patients, so most of the patients are reported on line 7 as uninsured.

9D

While the patient is uninsured, there is an "other public" payor for the service.  The clinic's usual and customary charge for the service is reported on line 7 in column A, and the payment is reported in column B.  Since the payment will almost always be different than the charge, the difference is shown as an allowance in column D.

9E

The grant or contract is not shown on Table 9E.  It is fully accounted for on Table 9D.

State or local safety net programs

description

These are programs which pay for a wide range of clinical services for uninsured patients, generally those under some income limit set by the program.  They may pay based on a negotiated fee-for-service, or fee-per-visit.  They may also pay "cents on the dollar" based on a cost report, in which case they are generally referred to as an "uncompensated care" program.

4

While patients may need to qualify for eligibility, these programs are not considered to be public insurance.  Patients served are almost always to be counted on line 7 as uninsured.

9D

The charges are to be considered charges directly to the patient (reported on line 13, column A).  If the patient pays any co-payment, it is reported in column B.  If they are responsible for a co-payment but do not pay it, it remains a receivable until it collected or is written off as a bad-debt in column f.  All the rest of the charge (or all of the charge if there is no co-payment) is reported as a sliding discount in Column E.

9E

The total amount received during the calendar year is reported on line 6a.

Workers Compensation

4

Workers Compensation is a form of liability insurance for employers , not a health insurance for employees .  Patient's whose bills are being paid by Workers Compensation should have a related insurance that is what is reported on Table 4 (even if it is not being billed or cannot be billed by the CHC.)  In general, if they had an employer paid / work-place based health insurance plan they would be reported on line 11.  If they do not have any health insurance, they are reported on line 7.

9D

Charges, collections and allowances for Workers Compensation covered services are reported on line 10.

Tricare, Trigon, Public Employees Insurance, etc.

4

While there are many individuals whose insurance premium is paid for by a government, ranging from military and dependents to school teachers to congressmen and HRSA staff, these are all considered to be private insurances.  They are reported on line 11, not on line 10a.

9D

Charges, collections and allowances are reported on lines 10 - 12, not on lines 7 - 9.

Contract sites

(In-scope sites in schools, workplaces, jails, etc.)

description

Some CHCs have included in their scope of service a site in a school a workplace, a jail, or some other location where they are contracted to provide services to (students / employees / inmates / etc.) at a flat rate per session or other similar rate which is not based on the volume of work performed.   The agreement generally stipulates whether and under what circumstances the clinic may bill third parties.

4

Lines 1-6 - income:       In general, income should be obtained from the patients.  In prisons, it may be assumed that all are below poverty (line 1).  In schools, income should be that of the parent or unknown or, in the case of minor consent services, below poverty.  In the workplace, income is the patient's family income or, if not known, "unknown" (Line 5).

Lines 7-12 - insurance:       Record the actual form of insurance the patient has.  Do not consider the agency with whom the clinic is contracted to be an insurer.  (Schools and jails are not "other public" insurance.)

5

Count all encounters as appropriate.  Do not reduce or reclassify FTEs for travel time.

8A

Costs will generally be considered as medical (lines 1-3) unless other services (mental health, case management, etc) are being provided.  Do not report on line 12-"other related services"

9D

Unless the encounter is being charged to a third party such as Medicaid the clinic's usual and customary charges will appear on line 10, column A.  The amount paid by the contractor is shown in column B.  The difference (positive or negative) is reported in column D.

9E

Contract revenue is not reported on Table 9E.

S-CHIP

4

Medicaid:      If S-CHIP is handled through Medicaid and the enrollees are identifiable, they are reported on line 8b.  If it is not possible to differentiate S-CHIP from regular Medicaid, the enrollees are reported on line 8a with all other Medicaid patients.

Non-Medicaid:       S-CHIP enrollees in states which do not use Medicaid are reported as "Other Public S-CHIP" on line 10b.  Note that, even if the plan is administered through a commercial insurance plan, the enrollees are not reported on line 11.

For information about the type of S-CHIP Program in your state: http://www.statehealthfacts.kff.org

9D

Medicaid:       Report on lines 1 - 3 as appropriate.

Non-Medicaid:       Report on lines 7 - 9 as appropriate.  Do not report on lines 10 - 12 even if the plan is administered by a commercial insurance company.

Carve-outs

description

Relevant to capitated managed care only.      Grantee has a capitated contract with an HMO which stipulates that one set of CPT codes will be covered by the capitation regardless of how often the service is accessed, and another set of codes which the HMO will pay for on a fee-for-service basis whenever it is appropriate.  Most common carve-outs involve lab, radiology and pharmacy, but specific specialty care or diagnoses (e.g., perinatal care) may also be carved out.

9C

Lines 1a/1b.      The actual capitation received from the HMO is reported on line 1a.  The additional amounts received as a result of the carve-outs are reported on line 1b.

Lines 5a/5b.      The cost of delivering the capitated services are reported on line 5a; the costs of delivering the carved-out services are reported on 5b.  The costs of the carved out services are generally calculated based on the associated charges, but are generally not just equal to those charges.

Lines 8a/8b, 10a/10b.       Member months and enrollees are counted only on the capitated lines (lines 8a and 10a)

Lines 9a/9b.       The encounters for the capitated patients are counted on line 9a.  No encounters are reported for the carved out services if the are a part of another encounter (e.g., the lab part) but encounters are reported if the service (e.g. prenatal care or HIV treatment) is carved out.

9D

Lines 2a/b, 5a/b, 8a/b, 11a/b.      Capitation payments are reported on the "a" lines, carve out payments are reported on the "b" lines.  The numbers will in general be the same as on Table 9C.

(Migrant) Vouchers

description

Voucher Programs have traditionally been an exclusive part of the Migrant and Seasonal Farmworker program, though in recent years some Homeless and even CHC programs have made use of the mechanism.  In this system, the center identifies services that are needed by its patients which cannot be provided by their in-house staff.  Vouchers are written to authorize a third party provider to deliver the services, and voucher is returned to the grantee for payment.  Payment is generally at less than the providers full fee, but is consistent with other payors such as Medicaid.

3a, 3b, 4

Patients are counted even if the only service that they receive is a vouchered service, provided that these services would make the patient eligible for inclusion if the Center provided them.  Thus a vouchered Taxi ride would not make the patient "countable" because transportation services are not counted on Table 5.

5

Column A:       There is no way to account for the time of the voucher providers.  As a result, zero FTEs are reported with regard to these services.  If there is a provider who works at the center, the FTE of that provider is counted.  For example, the one-day-a-week family practitioner would be reported as 0.20 FTEs on line 1.  But the 125 vouchered visits to FPs would not result in an additional count on line 1.

Column B:       Count all visits that are paid for by voucher.  DO NOT count visits where the referral is to a provider who is not paid in full for the service (i.e., a "voucher" to a doctor who donates five visits per week does NOT generate a visit that is counted on Table 5.

6

Diagnoses / Services.       The Voucher program is expected to receive from the provider a bill similar to a HCFA-1500 which lists the services and diagnoses.  These are to be tracked by the center and reported on Table 6.

8a

Cost of Vouchered Services.       The costs are reported on the appropriate line.  Medical vouchers are reported on Line 1, not Line 3.  Report only those costs paid directly by the grantee.

Discounts.       Virtually all clinical providers are paid less than their full fee.  Some grantees like to report the amount of these discounts as "donated services".  While this is not required, grantees may report the difference between the voucher provider's full fee and the contracted voucher payment as a donated service on line 18, column D.

9d

Column A:  Charges.       Report the full charge that the provider shows on their HCFA-1500 as the charge on line 13 - self pay.  Do not use the voucher amount as the full charge.

Column B:  Collections.       If the patient paid the voucher program a nominal or other fee, show this in column B.

Column E:  Sliding Discounts.       Show the difference between the full charge and the amount that the patient was supposed to pay in Column E.  Do not show the full amount in Column E if the patient was supposed to make a payment to the center and failed to do so.

Column F:  Bad Debt.       Show any amount (such as a nominal fee) that the patient was supposed to pay but failed to pay.  Bad debts are recognized consistent with the center's financial policies.  Amounts not paid may be considered a bad debt in 30 days or in a year - whatever is the center's policy.