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This document provides information about the
Federally Qualified Health Center (FQHC) Look-Alike
Program and instructions for submitting an application
for designation or recertification as a FQHC
Look-Alike. The requirements described in this
document are for health centers that serve a
population that is medically underserved as
defined in section 330 of the Public Health
Service (PHS) Act.
II.
LEGISLATIVE BACKGROUND FOR FEDERALLY QUALIFIED
HEALTH CENTERS |
The
Omnibus Budget Reconciliation Acts of 1989,
1990, and 1993 amended section 1905 of the Social
Security Act to create a new category of entities
under Medicaid and Medicare known as FQHCs.
The Social Security Act § 1905(l)(2))B)
defines an FQHC for Medicaid purposes as an
entity which:
“(I) is receiving a grant under section
330 of the PHS Act, as amended; (II)(i) is receiving
funding from such a grant under a contract with
the recipient of such a grant, and (ii) meets
the requirements to receive a grant under section
330 of such Act, (III) based on the recommendation
of the Health Resources and Services Administration
within the Public Health Service, is determined
by the Secretary to meet the requirements for
receiving such a grant including requirements
of the Secretary that an entity may not be owned,
controlled or operated by another entity, or
(IV) was treated by the Secretary, for the purposes
of part B of title XVIII, as a comprehensive
Federally funded health center as of January
1, 1990, and includes an outpatient health program
or facility operated by a tribe or tribal organization
under the Indian Self-Determination Act (Public
Law (P.L.) 93-638) or by an urban Indian organization
receiving funds under title V of the Indian
Health Care Improvement Act for the provision
of primary health services.”
A similar definition for Medicare purposes is
found at § 1861(aa)(4) of the Social Security
Act.
The
goal of the FQHC program is to maintain, expand
and improve the availability and accessibility
of essential primary and preventive health care
services and related “enabling”
services provided to low income, medically underserved
and vulnerable populations that traditionally
have limited access to affordable services and
face the greatest barriers to care. As fundamental
components of the health care “safety
net,” FQHCs provide a comprehensive system
of care reflective of the community’s
needs and available to all persons residing
in their service area(s), regardless of the
person’s or family’s ability to
pay for such services. The FQHCs further ensure
access to care by establishing a schedule of
discounts for persons unable to pay a full fee,
including nominal or no fees for services provided
to the poorest of the populations served, persons
whose incomes are below 200 percent of the Federal
poverty guidelines.
One of the cornerstones of the FQHC program
is community involvement in both the management
and governance of the health center. The FQHCs
must be governed by a community-based Board
of Directors, a majority of whom are users of
the health center’s services and who represent
the health center’s service area in terms
of demographic factors such as race, ethnicity
and gender. The Board must autonomously exercise
key decision-making regarding adoption and establishment
of operating and service policies, approval
of the budget and grant application, strategic
and operational planning, and the hiring and,
if necessary, dismissal of the executive director
or chief executive officer. In addition, the
involvement of third parties in health center
governance is specifically limited by Federal
policy.
To ensure that there are appropriate numbers
of health centers to serve the millions of uninsured
and underinsured populations throughout the
country, FQHC Look-Alike status was made available
to those health centers that do not receive
funding under section 330, but operate and provide
services similar to grant-funded programs. As
such, FQHC Look-Alike entities are expected
to demonstrate the same commitment as grantees
to serve all populations residing in their respective
medically underserved communities, and to satisfy
the administrative, management, governance and
service-related requirements unique to section
330 funded health centers.
The Balanced Budget Act (BBA) of 1997 (P.L.
105-33) modified the definition contained in
section 1905 of the Social Security Act for
a FQHC Look-Alike entity by adding the requirement
that an “entity may not be owned, controlled
or operated by another entity.” The Health
Resources and Services Administration’s
(HRSA) Bureau of Primary Health Care (BPHC),
in collaboration with the Centers for Medicare
and Medicaid Services (CMS), issued policy guidances
to implement the BBA requirements for public
and private nonprofit organizations: Policy
Information Notice (PIN) 99-10, “Implementation
of the Balanced Budget Act Amendment of the
Definition of Federally Qualified Health Center
Look-Alike Entities for Private Nonprofit Entities,”
issued April 20, 1999; and PIN 99-09, “Implementation
of the Balanced Budget Act Amendment of the
Definition of Federally Qualified Health Center
Look-Alike Entities for Public Entities,”
issued April 20, 1999. Other relevant policy
documents are PIN 97-27, “Affiliation
Agreements of Community and Migrant Health Centers,”
issued July 22, 1997; and PIN 98-24, “Amendment
to PIN 97-27 Regarding Affiliation Agreements
of Community and Migrant Health Centers,”
issued August 17, 1998. These documents describe
the statutory limits on the involvement of “another
entity” in the ownership, control and/or
operation of a public or private nonprofit FQHC
Look-Alike entity.Potential
applicants are encouraged to work closely with
the HRSA Field Offices list of contacts if there
are questions about the application of these
policies to their particular case.
III.
PAYMENT ELIGIBILITY UNDER MEDICAID AND MEDICARE |
Under Medicaid, the FQHC covered core services
include services provided by physicians, physician
assistants, nurse practitioners, clinical nurse
specialists, clinical psychologists, clinical
social workers, and services and supplies incident
to those services. Any other ambulatory service
included in a State's Medicaid plan is considered
a covered service under the FQHC benefit, if
the FQHC offers such a service and meets applicable
requirements for a provider of that service.
Under Medicare, FQHCs currently are eligible
for payment at 100 percent of the reasonable
costs for the same core services covered under
the Medicaid FQHC benefit.
Additionally,
Medicare FQHC includes reimbursement at 100
percent of reasonable cost for certain preventive
health services that are not normally covered
under Medicare.
The Medicaid prospective payment system (PPS)
for FQHCs was enacted into law on December 21,
2000, under section 702 of the Medicare, Medicaid
and State Children’s Health Insurance
Program (SCHIP) Benefits Improvement and Protection
Act (BIPA) of 2000. The new Medicaid PPS requirements
are effective in all States, with respect to
services furnished by FQHCs on or after January
1, 2001. All States, including those operating
section 1115 waiver demonstration programs,
are subject to the new Medicaid PPS requirements
in sections 1902(a)(15) and 1902(aa) of the
BIPA.
The BIPA amends section 1902(a) of the Social
Security Act (“the Act”) by repealing
the reasonable cost-based reimbursement requirements
for FQHC services (previously at paragraph (13)(C))
and instead requiring (in paragraph (15)) payment
for FQHCs consistent with a new PPS described
in section 1902(aa) of the Act. Under BIPA,
the new Medicaid PPS was effective on January
1, 2001. In the first phase of the new Medicaid
PPS (January 1, 2001-September 30, 2001), States
were required to pay current FQHCs either 100
percent of the average of their reasonable costs
of providing Medicaid-covered services during
fiscal year (FY) 1999 and FY 2000, adjusted
for any increase or decrease in the scope of
services furnished during FY 2001 by the FQHC
(calculating the payment amount on a per visit
basis), or an amount based on an alternative
payment methodology mutually agreed to by and
between the State agency and the FQHC (as described
below). Beginning in FY 2002, and for each fiscal
year thereafter, each FQHC is entitled to the
payment amount (on a
per visit basis) to which the center or clinic
was entitled under the Act in the previous fiscal
year, increased by the percentage increase in
the Medicare Economic Index (MEI) for primary
care services, and adjusted to take into account
any increase (or decrease) in the scope of services
furnished by the FQHC during that fiscal year.
Newly qualified FQHCs after FY 2000 will have
initial payments established either by reference
to payments to other clinics in the same or
adjacent areas, or in the absence of such other
clinics, through cost reporting methods. After
the initial year, payment shall be set using
the MEI methods used for other clinics.
For
the same period beginning January 1, 2001 and
ending September 30, 2001, and for any fiscal
year beginning with FY 2002, a State may, in
reimbursing an FQHC for services furnished to
Medicaid beneficiaries, use an alternative methodology
other than the Medicaid PPS, but only if the
following statutory requirements are met. First,
the alternative payment methodology must be
agreed to by the State and by each individual
FQHC to which the State wishes to apply the
methodology. Second, the methodology must result
in a payment to the center or clinic that is
at least equal to the amount to which it is
entitled under the Medicaid PPS. Third, the
methodology must be described in the approved
State plan.
Applicants
for FQHC Look-Alike designation must be operational
at the time of application and meet the following
requirements:
-
be a public or a private nonprofit entity;
-
serve, in whole or in part, a federally-designated
Medically Underserved Area (MUA) orMedically
Underserved Population (MUP). (The list of
MUAs and MUPs is available through the BPHC
Web site: http://www.bphc.hrsa.dhhs.gov/databases/newmua/);
-
meet the statutory, regulatory and program
requirements for grantees supported under
section 330
of the PHS Act; and
- comply
with the policy implementation documents specified
in Section II of this PIN for the
BBA of 1997 amendment which added the requirement
that an FQHC Look-Alike entity may
not be owned, controlled or operated by another
entity.
The submission of a Letter of Interest (LOI)
is recommended but not required in order to
submit an application for FQHC Look-Alike designation.
It is recommended that an applicant submit a
LOI to the BPHC as soon as it begins considering
applying for FQHC Look-Alike designation. A
copy of the LOI should be sent to the Primary
Care Association (PCA). The BPHC uses the LOI
process to provide feedback to the organization
to improve the quality of its application and
its opportunity for designation as a FQHC Look-Alike.
The BPHC will provide feedback within 30 days
of receipt of the LOI and the applicant should
incorporate the BPHC response prior to the application.
The LOIs should be no longer than 7 pages and
address the level of need in the community for
additional primary care services, provide a
description of the organization that will be
seeking the designation and a brief description
of the proposed project. Each LOI should include
a BRIEF DESCRIPTION of each of the following:
- the
name and address of the organization and sites
to be designated;
-
the proposed target population and service
area including whether
-
it is defined as urban or rural and
- identification
of any federally-designated MUA/MUP designations
to be served;
-
issues creating a high need for primary health
services including any significant or unique
barriers to care;
-
a justification of the need for FQHC Look-Alike
designation by documenting the lack of sufficient
health care resources in the service area
to meet the primary care needs of the target
population. A map of the service area with
the organization and sites noted, as well
as all other resources in the service area,
should be included;
-
the level of need in the community for additional
primary care services;
-
the history and mission of the organization
that will be seeking the designation;
-
current operational capacity of the organization,
providers and services; and
-
the signed compliance checklist and relevant
documents. (See Form 4).
LOIs may be sent via e-mail to fqhclaloi@hrsa.gov
or mailed to:
Bureau of Primary Health Care
4350 East-West Highway, 7th Floor
Bethesda, Maryland 20814
ATTN: FQHC Look-Alike LOI
A copy of the LOI should be sent to the appropriate
PCA. (See attached list, Appendix B).
For FQHC Look-Alike designation, an original
application and two copies of the application
must be submitted to the BPHC. Applications
are accepted anytime throughout the year. The
review and designation process is carried out
by staff of the BPHC, the CMS Central Office
(CO) and the CMS Regional Offices (RO)s. The
role and responsibilities of each entity are
as follows:
BPHC:
The BPHC is responsible for distributing application
materials, providing comments on LOIs, receiving
completed applications, and reviewing the application
for consistency and compliance with section
330 requirements and applicable policies. While
the BPHC review is usually completed within
a month of receipt of the application, it may
be necessary to request additional information
from the applicant to clarify various aspects
of or to correct minor deficienc ies in the
application. If the BPHC review concludes that
the application meets the requirements and expectations
of the FQHC Look-Alike program, the BPHC will
forward a recommendation for approval to the
CMS CO.
When the BPHC review determines that the application
is either non-compliant with FQHC Look-Alike
requirements or incomplete, the application
will be returned to the applicant without further
consideration. The organization may re-apply
for FQHC Look-Alike designation, however, the
application must demonstrate full compliance
with all requirements. The applicant is encouraged
to contact the PCA for assistance in addressing
any deficiencies prior to re-applying.
CMS CO and RO:
As defined by Section 1905 of the Social Security
Act, only the CMS has the statutory authority
to designate applicants as FQHC Look-Alikes,
based on the recommendation of the HRSA/BPHC.
After the BPHC forwards its recommendation for
designation to the CMS CO, the CMS CO forwards
a memorandum to the appropriate CMS RO requesting
the applicable State Medicaid Agency/Office
be notified of the applicant organization’s
pending designation as a FQHC Look-Alike.
The State Medicaid Agency/Office has 14 days
to comment on the application and submit any
additional information to the CMS RO regarding
the designation. If the CMS CO receives no comments,
the recommendation will be accepted and the
applicant organization will be designated as
a FQHC Look-Alike. The CMS RO then notifies
the State Medicaid Agency/Office, the CMS CO,
and the BPHC of the final approval decision
and the BPHC then notifies the applicant organization
of the final approval decision. Generally, the
effective date of the FQHC Look-Alike designation
is the date of the CMS RO letter to the State
Medicaid Agency/Office regarding the final approval
decision.
In some cases, a State may request a 60 day
extension to investigate any issues raised during
the initial 30 day comment period. If the issues
are not satisfactorily resolved within the 60
day extensio n, the CMS CO will notify the applicant
and the BPHC that the recommendation for FQHC
Look-Alike designation will not be accepted.
The BPHC will notify the applicant and the PCA.
The applicant may continue to work with the
State to resolve any outstanding issues and
reapply for designation when the issues have
been resolved.
VII.
340 DRUG PRICING PROGRAM |
Organizations designated as FQHC Look-Alikes
under section 330 of the PHS Act, as amended,
are eligible to purchase prescription and non-prescriptio
n medications for their outpatients at reduced
cost through the 340B Drug Pricing Program.
FQHCs are not required to operate/own a pharmacy
in order to participate in this program. Given
the pharmacist shortage nationwide, FQHCs may
want to consider contracting with a local pharmacy.
In order to participate in this program, a health
center must submit a Program Registration Form
to the Office of Pharmacy Affairs, Bureau of
Primary Health Care along with its Medicaid
information.
For general information on the 340B program,
please contact the Office of Pharmacy Affairs
at 800-628-6297.
VIII.
SUPPLEMENTARY DOCUMENTS |
Applicants are encouraged to thoroughly review
the following reference documents prior to finalizing
a decision to apply. All policy documents are
posted on the BPHC web site:http://www.bphc.hrsa.gov/.
- Health
Centers Consolidation Act of 1996 (P.L. 104
– 299) (section 330 of the PHS Act,
as amended)
-
PIN 98-12, “Implementation of the Section
330 Governance Requirements” (signed
April 28, 1998)
- PIN
98-23, “Health Center Program Expectations”
(signed August 17, 1998)
-
PIN 98-24, “Amendment to PIN 98-27 Regarding
Affiliation Agreements of Community
and Migrant Health Centers” (signed
August 17, 1998)
-
PIN 97-27, “Affiliation Agreements of
Community and Migrant Health Centers”
(signed
July 22, 1997)
IX.
STRUCTURE AND CONTENT OF THE APPLICATION |
The requirements that must be fully addressed
by the applicant are detailed in Attachment
A of this PIN. The total narrative portion of
the application should not exceed 25 pages,
exclusive of required attachments, data exhibits
and relevant supporting materials. Minor deviations
from these limits are acceptable.
Applicants should submit an original
and one copy of the application, with all attachments,
to the BPHC and one copy to the appropriate
PCA. (See Appendix B).
A. STRUCTURE OF THE APPLICATION FOR DESIGNATION
(APPLICATION
COMPONENTS SHOULD BE ASSEMBLED AS FOLLOWS):
-
Form 1-A, Application for FQHC Designation
cover page. This must be notarized.
- Table
of Contents
- Form
2, Application Checklist
- Form
3, Compliance Checklist
-
Project Summary
-
Project Description – Narrative component
- Appendices
- Data
Tables 1 - 5
- Forms
4 - 5
- Required
Attachments
- Supplementary
Attachments (at the discretion of the
applicant)
B. CONTENT OF THE APPLICATION
1. PROJECT SUMMARY (recommend approximately
2 pages)
The project summary is intended to be a brief
synopsis of the community/target population,
the applicant organization and the scope of
the proposed FQHC Look-Alike. The applicant
should summarize the need for health services
in the community and the organization’s
response to that need. The following issues
should be addressed:
- Overview
of the community/population
-
Overview of the organization
- Project
plan
2. PROJECT DESCRIPTION
The narrative component of the application should
be divided into four sections:
-
Section A. Need and Community Impact;
- Section
B. Health Services;
-
Section C. Management and Finance; and
-
Section D. Governance. (See Attachment A for
further detail on the required elements to
be addressed in each section).
3. REQUIRED ATTACHMENTS
In addition to the data exhibits and tables,
the following documents MUST
be submitted with the application:
- documentation
of non-profit status or evidence of application
for non-profit status (not required for a
public entity applicant);
- a
map of the service area, with site location(s)
and MUA/MUPs noted, as well as other primary
care providers including other including other
FQHCs in the area
(see Appendix C for sample);
-
a complete copy of the applicant's most recent
annual audit with auditor’s opinion
letter;
- a
copy of the organization's schedule of discounts
(see Appendix A for sample);
-
signed copies of the organization’s
Articles of Incorporation and corporate bylaws;
and
- copies
of current or proposed management agreements,
administrative or clinical services contracts,
lines of credit, or any other type of formal
affiliation relationship.
C. MULTIPLE SERVICE DELIVERY SITES
Organizations requesting designation of more
than one service delivery site are not required
to submit a separate application for each site.
For each site being included in the designation,
the following must be included: (1) a narrative
description of need in the area, (2) demographics
of the target population, (3) services provided,
and (4) professional staffing. Tables 1-5 must
be submitted for each site. The submission of
information concerning user characteristics
such as income and insurance status, age, sex
and race on a site specific basis is preferred,
but if the entity only keeps aggregated data
on users, an entity-wide summary may be provided.
Allowance will be made for the increased size
of the application due to the submission of
information on multiple sites.
X.
ANNUAL RECERTIFICATION OF FQHC DESIGNATED
ORGANIZATIONS |
All designated FQHC Look-Alikes are required
to submit an annual recertification statement
to retain designation as a FQHC Look-Alike.
The annual recertification statement must be
notarized and submitted to the BPHC at least
2 months prior to the anniversary of the FQHC
Look-Alike’s designation date. The recertification
statement requires updated information on users,
staffing, and service delivery arrangements
(for each designated site if applicable), as
well as information on any administrative, management
or clinical changes that have taken place during
the past 12 months, including new or revised/amended
contracts and affiliation agreements. All changes
in scope approved during the previous year should
also be addressed (see below). (See Attachment
B – Requirements for Annual Recertification
for FQHC Look-Alike Designated Organizations).
The BPHC will review the recertification and
either contact the organization for additional
information or submit a recommendation to recertify
to the CMS CO. The CMS CO then notifies the
appropriate CMS RO who will notify the State
Medicaid Agency/Office with copies to the CMS
CO and the BPHC. The BPHC will notify the FQHC
Look-Alike of the continued designation.
If issues of compliance are raised during the
review of the recertification, the BPHC will
contact the organization for their response
to the is sues to assure continued compliance
with the FQHC Look-Alike program. If all the
issues are resolved satisfactorily within 60
days of notification, the BPHC will notify CMS
CO of its recommendation to recertify. If all
the issues are not satisfactorily resolved after
60 days, the organization will be notified by
the BPHC that the FQHC Look-Alike designation
will expire immediately.
In the event that a designated FQHC Look-Alike
does not submit the documentation required for
its annual recertification by the anniversary
of the designation date, the BPHC will notify
the FQHC Look-Alike, which, in turn, will have
30 days to submit the documentation. If the
FQHC Look-Alike does not submit the documentation
within the 30 day period, CMS will be notified
by the BPHC and the FQHC Look-Alike designation
will be terminated.
XI.
CHANGE IN SCOPE OF PROEJCT |
The Scope of Project defines the health center’s
approved project for the FQHC Look-Alike designation.
An approved scope of project may be a part of
a larger health care delivery system and, as
such, needs to be distinctly defined within
that context. FQHC Look-Alike health centers
may have other activities that are not part
of their approved scope of project, referred
to as Other Lines of Business (OLB) and, thus,
are not subject to section 330 requirements
and expectations. It is important to
note that only those activities that are a part
of the health center’s approved scope
of project are entitled to certain benefits
(i.e., Medicaid PPS and FQHC payments, Medicare
FQHC reimbursements, and Drug Pricing benefits).
(Note: Services that are within the
approved scope of project but that are not covered
as a FQHC service by Medicaid or Medicare, or
not provided on an outpatient basis, are not
eligible for PPS or cost-based reimbursement.)
A Scope of Project is categorized by five core
elements: services, sites, providers, target
population, and service area(s) and:
- Defines
for the section 340B Drug Pricing Program,
the necessary site information enabling covered
entities to purchase discounted drugs for
patients;
-
Defines the approved service delivery sites
and services necessary for State Medicaid
Offices to calculate payment rates under the
PPS or other State-approved alternative payment
methodology (see Program Assistance Letter
2001-09 Department of Health and Human Services
Fiscal Year 2001 Appropriations, Other Legislation,
and Regulation Issuances) and subsequent information
posted on www.bphc.hrsa.gov;
and
-
Defines the approved service delivery sites
necessary for the CMS to determine a health
center’s eligibility for FQHC Medicare
cost-based reimbursement.
All FQHC Look-Alike health centers must request
prior approval from the BPHC of any changes
to their approved scope of project. The requests
are to be submitted to the BPHC at least 60
days before the change is anticipated to take
place. All Change in Scope requests must demonstrate
approval by the Board of Directors and include
the Change in Scope Assurances Checklist (Form
6). If the change in scope includes additional
site(s) that have a different service area and/or
target population than those already being served,
Board representation must be modified to represent
users of the added site(s). The Cha nge in Scope
request may not be included as part of the recertification
package but must be submitted as a separate
request from the organization. The request should
state whether it is to add a new site(s) or
service(s), reduce services at an existing site(s),
or decrease the number of previously approved
sites, and must include all the required
documentation (as described below).
A. REQUESTS TO ADD OR DECREASE SITE(S)
Change
in Scope requests to add or decrease site(s)
must include:
-
a narrative description of need in the area
served by each site, demographics of the target
population, services provided at the site,
and professional staffing, and a description
of the impact of adding a or decreasing a
site while ensuring the financial viability
of the health center
-
map of the new site(s) service area, with
site(s) location and MUA/MUPs noted, as well
as other primary care providers (including
other FQHCs) in the new or deleted site’s
service area
-
any applicable referral agreements
-
Tables 1-5 completed for each new or deleted
site
-
updated Form 5, Service Sites
- Change
in Scope Assurances Checklist (Form 6)
B.
REQUESTS TO ADD OR REDUCE SERVICE(S)
Change in Scope requests to add or reduce services
must include:
- a
narrative description of the services and
the impact of adding or reducing service(s)
while ensuring the financial viability of
the health center.
-
updated Table 1
-
any applicable referral agreements
-
Change in Scope Assurances Checklist (Form
6)
ATTACHMENTS,
APPENDICES, AND FORMS |
REQUIREMENTS
FOR DESIGNATION AS A FQHC LOOK-ALIKE
It is important that the applicant fully address
ALL requirements within the narrative component
of the application. Submission of data tables
without supportive narrative information may
result in an application being returned to the
applicant as an incomplete application. Health
Center Program Expectations (PIN 98-23, dated
August 17, 1998) contains a detailed description
of the requirements for grantees under section
330 of the PHS Act and provides the basis for
FQHC Look-Alike requirements. The FQHC Look-Alike
entities are to be governed by these expectations
to the same extent as federally supported health
centers. This PIN, and others, are available
through the BPHC Web site http://www.bphc.hrsa.gov/pinspals/.
Listed below are the required areas to be addressed
in each of the four narrative sections and the
information the applicant must provide to demonstrate
compliance with the program requirements.
SECTION A. NEED AND COMMUNITY IMPACT
Each FQHC Look-Alike is expected to gain a thorough
knowledge of the community and populations groups
it intends to serve. In particular, the entity
must assess and understand the needs, resources
and priorities of the underserved populations
residing in its community and design a health
care program that is culturally and linguistically
appropriate to those populations. Needs and
resources should be monitored on an ongoing
basis and comprehensively assessed on a periodic
basis.
Requirements:
-
Applicants must demonstrate the need for primary
health care services in the community(ies)
that make up its service area based on geographic,
demographic, and economic factors.
-
Applicants must justify the need for FQHC
Look-Alike designation by documenting the
lack of sufficient health care resources in
the service area to meet the primary health
care needs of the target population. If there
are other FQHCs located in the applicant’s
proposed service area, the applicant should
address the need for additional FQHC services,
as well as any efforts to collaborate with
existing FQHCs.
- Applicants
must demonstrate that the health center location
will permit it to provide services to the
greatest number of those in need in the service
area.
-
Applicants must demonstrate that it is serving
those most in need within the service area,
including low income and special need individuals/groups,
such as the uninsured, minorities, pregnant
women, the elderly, and, where applicable,
migrant or seasonal farmworkers, HIV- infected
persons, the homeless, and substance abusers.
- Applicants
must serve, in whole or in part, a designated
MUA or MUP.
In order to demonstrate that it meets the requirements
of 1 - 5 above, the applicant should provide,
at a minimum, the following information:
A. A narrative description of the Service Area,
which includes:
- the
geographic boundaries of the service area
of the health center, e.g., the names of counties,
localities and/or census tracts;
-
a description of the major health problems
and special health needs of the target population
within the service area, and a description
of any unique health status indicators or
barriers to their accessing health care;
- identification
of the unserved and underserved populations
in the community;
- the
geographic area and/or population groups that
constitute its principal target population,
including any unique populations (for example
migrant/seasonal farmworkers);
-
the characteristics of the target population
in terms of age, gender, socioeconomic status,
health insurance status, ethnicity/culture,
education, language, health status, unemployment,
poverty level, etc.;
-
other providers of health and social services
accessible to the population; and
-
gaps in services and health disparities the
health center proposes to address.
B. A narrative description of the user population,
which includes:
- total
number of users and total number of encounters
for the most recent 12-month period available
(state the period covered by the data);
-
economic, demographic and other characteristics
identified in Section A above, as they apply
to the user population, and;
-
the major health needs of the user population,
including any special health care needs among
population segments (migrant/seasonal agricultural
workers, public housing residents, homeless
persons, low-income school children, etc.).
C. A map of the service area that clearly shows
the location of the applicant's service area;
the applicant’s service delivery site(s);
the designated MUA/MUP(s) served; and the other
providers (including other FQHCs) in the area
available to the target population.
Tables 1-5 are required formats for providing
demographic information on the service area
and user populations. Information provided in
the Tables should also be described in the narrative.
As previously noted, organizations that provide
services through more than one service delivery
site must submit the information from sections
A and B above, including all tables, for each
site included in the application. Please identify
other FQHCs in the proposed service area and
the need for additional FQHC services, as well
as any efforts to collaborate with existing
FQHCs.
SECTION B. HEALTH SERVICES
The FQHC Look-Alikes must have a system of care
that contributes to the availability, accessibility,
quality, comprehensiveness and coordination
of health services in the service area. They
must ensure that basic primary health care and
support services appropriate to the health needs
of the target population are available and accessible
to all persons in the service area, regardless
of ability to pay. They must also have a sufficient
number and range of qualified providers and
a clinical management system that ensures quality
and continuity. Program accountability must
be maintained by the applicant.
Applicant organizations are expected to collaborate
appropriately with other health and social service
providers in their area. Such collaboration
is critical to ensuring the effective use of
limited resources and for achieving the mission
of assuring access to primary and preventive
health care for the underserved and vulnerable
populations. While health centers are encouraged
to collaborate with other entities, they must
ensure that all laws, regulations and expectations
regarding the health center governing board
member selection process, composition, functions
and responsibilities are protected. Accountability
must be maintained by the health center and
its governing board. The BPHC PINs 97-27, 98-24,
99-09 and 99-10 provide policy clarification
regarding limits on FQHC Look-Alike affiliation
relationships. Information regarding any proposed
affiliation arrangements will be used to assure
that organizations comply with the requirements
and guidelines set forth in the above BPHC PINs,
including the center directly employs the Chief
Financial Officer, Chief Medical Officer and
the core staff of full-time primary care providers,
the center directly employe es all non-provider
health center staff, and the arrangements presented
in affiliation agreements do no compromise the
Governing Board authorities or limit its legislative
and regulatory mandated functions and responsibilities.
Requirements:
1. Required Primary Health Services: The applicant
must demonstrate that it provides the following
services, either directly, through contract,
or through documented cooperative arrangements
(see Table 1) and access must be assured for
all patients regardless of ability to pay:
A. Primary health care services by physicians,
and, where appropriate, mid-level practitioners
-
family medicine
- internal
medicine
- pediatrics
- obstetrics
- gynecology
B. Diagnostic laboratory services
C. Diagnostic radiologic services
D.
Preventive health services
-
prenatal and perinatal services
-
screening for breast and cervical cancer
- well-child
services
-
immunizations against vaccine-preventable
diseases
- screenings
for elevated blood lead levels, communicable
diseases, and cholesterol - pediatric eye,
ear and dental screenings to determine the
need for vision and hearing correction and
dental care
-
voluntary family planning services
-
preventive dental services
E. Emergency medical services
F. Pharmaceutical services as may be appropriate
for the health center
G. Referrals to providers of medical services
and other health related services
-
substance abuse services
-
mental health services
- oral
health services
H. Patient case management including a system
for tracking and follow-up
I. Enabling services
- outreach
-
transportation
- language
interpretation if a substantial number of
patients are of limited English
proficiency
1. Education regarding the availability and
proper use of health services Additional services
may be critical to improve the health status
of a specific community or population group.
Services beyond the required health center services
should be provided based on the needs and priorities
of the community, the availability of other
resources to meet those needs, and the resources
of the organization.
2.
The applicant must demonstrate that all contracted
services (including management agreements, administrative
services contracts, etc.) remain under the governance,
administration, clinical management and quality
assurance of the applicant organization.
3. The applicant must assure all required services
are available to all persons in the service
area or target population. Services may not
be limited by race, group affiliation, age,
gender, or the patient’s ability to pay.
This requirement may be achieved directly by
the applicant or through established arrangements
that meets the collaboration and/or contracting
arrangements described on page 15.
4. The applicant must demonstrate that the organization
maintains, either directly or through contractual
arrangements, a core staff of full- time primary
care providers appropriate for the population
served (i.e., family practice, pediatricians,
internists, etc., physicians and midlevel practitioners).
(See Table 3 for required format). A core staff
of several part-time employees
does not meet this requirement. Applicants that
do not directly employ a core staff of primary
care providers are subject to the requirements
in PIN 98-24 regarding contracting for core
staff.
5.
All of the primary care providers working at
the health center must be licensed to practice
in the State where the center is located.
6. The applicant's physicians should obtain
admitting privileges at their referral hospital(s)
so health center patients can be followed as
inpatients by health center clinicians in order
to ensure continuity of care. When this is not
possible, the applicant must have firmly established
arrangements for patient hospitalization, discharge
planning and patient tracking.
7. The applicant must provide assurance that
services are available to all persons within
the service area, regardless of their ability
to pay.
8. The applicant must demonstrate use of a charge
schedule with a corresponding discount schedule
based on income for persons between 100 percent
and 200 percent of the Federal poverty level
(see Appendix A for a sample schedule of discounts).
Patients below 100 percent of the Federal poverty
level should not be charged more than a nominal
fee.
9. The applicant's health center should be open
at least 32 hours per week, with services provided
at times that meet the needs of the majority
of potential users (including evenings and/or
weekends as appropriate).
10. The applicant must provide professional
coverage during hours when the health center
is closed. Applicant must demonstrate firm arrangements
for after- hours coverage by their own providers
and/or, if necessary, by other community providers.
The arrangements must ensure telephone access
to a health care provider who is part of the
health center's after-hours system;
11. The applicant must have an ongoing quality
assurance program that identifies problems and
allows for necessary actions to remedy problems.
In order to demonstrate that it meets the requirements
of 1-11 above, the applicant should provide,
at a minimum, the following information:
A. A check list showing which of the required
services are provided directly, by contract,
or by a documented cooperative arrangement (see
Table 1), and a discussion in the narrative
of how each of these services is provided. For
services provided through contracting
arrangements, the applicant must demonstrate
that the services remain under the governance,
administration and clinical management of the
applicant organization. All contracts should
state the time period during which the agreement
is in effect, the specific services it covers,
any special conditions under which the services
are to be provided, and the terms for billing
and payment. Copies of all contract documents
must be submitted with the application. Health
centers may be eligible for FQHC reimbursement
of the cost of contracted services; however,
they are not eligible to receive FQHC reimbursement
for referred services not paid for by the health
center.
B. A description of its clinical staff, including:
-
Who provides clinical leadership, their training
and skills, and the reporting relationship
between that individual and the Chief Executive
Officer (CEO).
-
Authorities and responsibilities of the clinical
director are expected to include: 1) leadership
and management for all health center clinicians
whether employees or contractors; and 2) ability
to function as an integral part of the management
team.
-
The current physician and mid-level staffing
(i.e., the number, FTEs and discipline of
providers, licensure, board certification/eligibility
status or completed residency training program),
hospital admitting privileges, whether directly
employed or provided under contract, and the
reporting relationship of contract providers
to the clinical director and/or CEO. (See
Table 3 for the format. Describe all aspects
in the narrative section.)
- The
availability of specialty medical and diagno
stic services through a system of contractual
or organized referral arrangements. These
services must be available to all regardless
of ability to pay.
C. Written clinical policies and procedures,
which address, at a minimum:
- Days
and hours per week of operation which assure
accessibility for the population being served.
Applicant should provide a schedule of the
days and hours each site is open each week,
and the schedule of days and hours that providers
are available to see patients.
-
After-hours coverage arrangements which assure
a continuum of care for center users, i.e.,
patients must have direct access to a provider.
- Assurance
of the availability of services to all persons
in the service area or target population,
regardless of their ability to pay, and the
organization’s sliding fee schedule.
-
The use of clinical protocols.
- Procedures
for assessing patient satisfaction.
D. A description of the case management system
that demonstrates care coordination at all levels
of health care, including arrangements for referrals,
hospital admissions, discharge planning and
patient tracking. The system must ensure a continuum
of care.
E. A description of the ongoing quality assurance
program, including patient satisfaction and
patient grievance procedures. The applicant
should discuss how it integrates and applies
the components of the quality assurance system
into its planning and management, as well as
into the evaluation of its overall program effectivene
ss, i.e., utilization and peer review.
F. A description of the arrangements or plan
to provide services for individuals with limited
English-speaking ability with respect to bridging
language and cultural differences. The applicant
should discuss assurances that care is provided
in a culturally, linguistically and appropriate
manner.
SECTION C. MANAGEMENT AND FINANCE
To meet the challenge of efficient and effective
operation, FQHC Look-Alikes must have a strong
management team. Center management must work
with the governing board and operationalize
the health center’s mission and strategic
objectives. They must operate within available
resources, respond to opportunities, and plan
for future events. Management involves a team
process, and must be supported by strong personnel,
financial, information and clinical systems.
Health centers are encouraged to affiliate with
other entities to strengthen their ability to
achieve their mission of assuring access to
primary and preventive health care for the underserved
and vulnerable populations. The BPHC recognizes
that there are certain situations in which there
are exceptions to the BPHC’s preference
that health centers directly employ personnel
in certain positions (CFO, CMO, clinicians)
may be necessary and appropriate in order to
maximize access to comprehensive, efficient,
cost-effective, and quality health care.
PIN 98-24 clarifies PIN 97-27 with respect to
affiliation arrangements that involve a community
and migrant health center contracting fo r the
services of a Chief Financial Officer, Chief
Medical Officer and/or the majority of its primary
care clinicians The requirement that the health
center
directly employ the Executive Director remains
in effect.
Requirements:
1. Management Structure:
The applicant must demonstrate a line of authority
from the Governing Board to a chief executive
(President, CEO or Executive Director) who delegates,
as appropriate, to other management and professional
staff. The CEO must be directly emp loyed by
the health center. NOTE: It is preferable, but
not required, that all other key management
staff be directly employed by the health center
(see PIN 98-24).
The other key management staff should include:
a) a Fina nce Director (Chief Financial Officer
(CFO), Fiscal Officer) who is responsible for
financial affairs and reports to the CEO, and
b) a Clinical and/or Medical Director who is
responsible for clinical services and programs
and who participates actively in management
activities and decisionmaking. In some situations
(i.e., small centers) the CEO may also serve
as the Finance Director or Medical Director;
in other situations (i.e., integrated service
delivery networks), the Finance Director or
Medical Director may operate at the network
level.
2. Management Information Systems:
The applicant must have systems which accurately
collect and organize data for reporting and
which support management decision- making. The
applicant must be able to integrate clinical,
utilization and financial information to reflect
the operations and status of the organization
as a whole.
3. Financial Systems:
The applicant must have accounting and internal
control systems separate and specific to the
proposed FQHC Look-Alike entity, and appropriate
to the size and complexity of the organization.
An accounting system reflecting Generally Accepted
Accounting Principles which accurately reflects
financial performance must be in place. Separation
of function appropriate to organizational size
should be implemented to safeguard assets. Appropriate
and regular financial reports to reflect the
current financial status of the organization
are necessary to good management.
While FQHC Look-Alikes are expected to ensure
access to their services without regard for
a person's ability to pay, they are also expected
to maximize revenue from third party payers
and from patients to the extent they are able
to pay. To meet these expectations, each FQHC
Look-Alike must have in place written billing,
credit and collection policies and procedures,
which include:
-
a system for billing patients and third parties
within 45 days of a service being rendered;
- a
procedure for aging accounts receivable;
-
a procedure for producing appropriate aging
reports;
- a
procedure for following up on overdue accounts
to ensure collection;
-
a procedure for handling bad debts on a regular
basis; and
-
a procedure for internal controls.
4. The applicant must demonstrate that it is
responsible for ensuring that an annual independent
financial audit is performed in accordance with
Federal audit requirements. Audits for nonprofit
organizations must follow Office of Management
and Budget (OMB) Circular A-133 "Audits
of Institutions of Higher Education and Other
Nonprofit
Institutions." Audits of public entities
and those nonprofit organizations under mandate
OMB No.
by the State (i.e., those also receiving a threshold
level of state financial assistance) must comply
with the Single Aud it Act of 1984 and, therefore,
are subject to the audit requirements of OMB
Circular A-128, "Audits of State and Local
Governments." The audit report must provide
an opinion on the scope of the audit, the fairness
of the applicant's financial statements, and
an evaluation of the applicant's system of internal
accounting controls. The auditor shall determine
whether the applicant is operating in accordance
with generally accepted accounting principles.
The applicant should receive an unbiased opinion
to that effect. Any problems cited in the audit
or report on internal controls must be explained,
and adequate procedures must be in place to
correct those problems.
5. As a test of fiscal soundness, the applicant
must demonstrate that revenues for the proposed
FQHC Look-Alike equal at least 90 percent of
expenditures. Revenues and expenditures are
to be reported in the application and substantiated
by an independent financial audit.
6. The applicant must be, or has applied to
be, a Medicaid provider.
7.
The applicant must be, or has applied to be,
a Medicare provider.
In order to demonstrate that it meets the requirements
of 1-7 above, the applicant must provide, at
a minimum, the following information:
A. An organizational chart showing the organizational
and management structure and lines of authority,
key employee position titles and names, and
the actual FTEs devoted to the health center
operation. The Board and individuals with the
following responsibilities should be clearly
identified: CEO, Clinical Director, and CFO/Financial
Manager.
.
B. A description of data systems in place to
accurately collect and organize data for required
reporting of program related statistics, as
well as for internal monitoring, quality improvement
and the support of manageme nt decisions and
planning.
Applicant should be able to integrate clinical,
administrative, and financial information to
allow adequate monitoring of the operations
and status of the organization as a whole.
C.
A description of financial systems, including
accounting and internal controls in place that
ensures the fiscal integrity of financial transactions
and reports. Specifically, this should include
a description of:
1. the accounting and internal control systems
appropriate to the size and complexity of the
organization;
2. the billing, credit and collection policies
and procedures (i.e., patient and third party
billing, aging accounts and producing reports,
following up on overdue accounts and the handling
of bad debts), including current fee schedules
for all billable services, which should be updated
annually, covering all reimbursable costs and
comparable in the aggregate to prevailing fee
schedules in the area;
3. the financial checks and balances for accounts
receivable; and provisions for ensuring that
an annual independent audit is performed.
D. A complete copy of the applicant's most recent
annual audit, including the auditor’s
opinion statement (cover letter.)
The application should list the applicant's
Medicaid and Medicare provider numbers. Applicants
that do not have a Medicaid and/or Medicare
provider number at the time of application should
demonstrate that applications have been submitted.
SECTION D. GOVERNANCE
An FQHC Look-Alike must be governed by a Board
of Directors which is representative of the
community and users being served and which has
full authority and responsibility as required
by the section 330 of the Public Health Service
Act governing regulations and program policies.
The governing board is legally responsible for
ensuring that the FQHC Look-Alike is operated
in accordance with applicable Federal, State
and local laws and regulations. It carries out
its legal and fiduciary responsibility by providing
policy level leadership and by monitoring and
evaluating all elements of the FQHC Look-Alike’s
performance.
The governance requirements under section 330
are unique among health service programs and
are the basis for ensuring that each FQHC Look-Alike
is responsive to the needs of the community.
The requirements presented below are essential
for assuring a responsive board with the necessary
authority and responsibility over the FQHC Look-Alike’s
operations. The requirements are expected to
be addressed in the applicant’s bylaws.
Requirements:
1. Applicant must demonstrate that it is either
a private non-profit organization or a public
entity.
2. Applicant must demonstrate that it has a
governing Board that:
a. Is comprised of at least 9 but no more than
25 members.
b. At least 51 percent of the governing board's
members must be active users of the FQHC Look-Alike’s
services and must reasonably represent the individuals
served by the health center in terms of such
factors as race, ethnicity, and gender. These
factors are not, however, meant to impose quotas.
As a general rule, user board members should
live and/or work in the service area.
c. No more than one-half of the non- user members
may be health professionals, which is defined
as deriving more than 10 percent of the ir income
from the health care industry. An individual's
leadership role in the community and functional
expertise should be major criteria in selecting
non-user members. As a general rule, non-user
board members should live and/or work in the
service area.
3. a. For private, non-profit organizations,
the governing board must meet at least once
a month, and be vested with full authority and
responsibility for health center operations.
At a minimum, the board must have the authority
to:
- select
the services to be provided by the center;
-
schedule the hours during which such services
will be provided,
- approve
the center's budget and major resource decisions,
- establish
general policies for the center, and
- select,
dismiss and evaluate the performance of the
Executive Director/CEO for the center.
b. For public entities, the governing board
must meet at least once a month and have the
following authorities:
- select
the services to be provided by the center;
- approve
the center’s budget;
- approve
the selection and dismissal of the CEO/ Executive
Director;
- adopt
health care policies;
- assure
center is operated in compliance with applicable
laws and regulations, and
-
evaluate center activities. A public entity
may achieve compliance in two ways.
First,
the public entity Board may itself meet all
the requirements of section 330 of the Public
Health Service Act. In the second form of public
center, there is a public entity applicant with
a co-applicant entity which, when combined,
meet all the requirements of section 330 of
the Public Health Service Act. In co-applicant
arrangements, the public entity receives the
FQHC Look-Alike designation and the co-applicant
entity serves as the “health center board,”
with the two collectively referred to as the
“health center.” Where responsibilities
are split between the co-applicant board and
the public entity, the public agency and the
board MUST execute an agreement which defines
each party’s role, responsibilities and
authorities. For example, the public entity
may retain authority to establish general fiscal
and personnel policies for the center. (See
PIN 99-09 for specific requirements).
4. The applicant’s by-laws must demonstrate
compliance with the requirements of section
330 of the Public Health Service Act and include
provisions that prohibit conflict of interest
or the appearance of conflict of interest by
board members, employees, consultants and those
who provide services or furnish goods to the
applicant. No board member may be an employee
of the center or be an immediate family member
of an employee. In order to demonstrate that
it meets the requirements of 1 – 4 above,
the applicant should provide, at a minimum,
the following information:
A. For a private, non-profit organization, evidence
of non-profit status (e.g., a letter from the
State or the Federal government, or a copy of
the Articles of Incorporation filed with the
State, designating the organization as having
such, or evidence that an application for non-profit
status has been submitted).
B. For a private, non-profit organization, evidence
of current or pending tax exempt status (Internal
Revenue Service (IRS) Tax Exempt Certification
for the Applicant or acknowledgement of request
to the IRS for exemption). For a public entity
applicant, evidence of the Co-Applicant Board’s
current or pending tax exempt status (IRS Tax
Exempt Certification or acknowledgement of request
from IRS) if independently incorporated.
C. A list of board members, including user status,
occupation, area of professional expertise,
and residence and/or employment within the service
area (see Table 5). Board officers should be
indicated on this list as well. Applicants with
a formal affiliation relationship with another
entity must demonstrate compliance with PIN
97-27 regarding the board selection process
(no other entity or entities may select a majority
of the health center board members or select
a majority of the non-user members), composition,
authorities, and committee structure. These
issues should be addressed in the narrative
if not fully covered in the attached corporate
documents or affiliation agreements.
D. A description of the governing board's authorities
and responsibilities. There must be documentation
(i.e., in the bylaws) that the governing board
has the authority to, at a minimum, 1) select
the services to be provided; 2) schedule the
hours during which services will be provided;
3) approve the center's annual budget and major
resource decisions; 4) adopt administrative,
health care, financial and personnel policies;
and 5) select, dismiss and annually evaluate
the performance of the CEO for the FQHC Look-Alike.
The governing board’s authorities, meeting
schedule, composition and selection process
must also be specified in the organization’s
by-laws.
E. For public entities with a co-applicant board,
a copy of the written agreement between the
public agency and the co-applicant board, identifying
the authorities, duties and responsibilities
of each entity must be submitted.
F. A description of procedures for avoidance
of Conflict of Interest. This description must
be included in the organization’s by-
laws.
G. Indicate whether the entity is currently
a hospital outpatient department or part of
a hospital outpatient department, and whether
it is currently certified by Medicare or Medicaid
as part of a hospital.
ATTACHMENT
B
REQUIREMENTS
FOR ANNUAL RECERTIFICATION FOR FQHC LOOK-ALIKE
DESIGNATED ORGANIZATIONS
To fulfill the requirements for recertification,
all designated FQHC’s must submit updated
information, by site if applicable, which reflects
the previous 12 months and includes information
on the following:
1. Completed Form 1-B – notarized
2. A brief description of and any changes in:
-
the number of users and encounters;
-
characteristics of the user population;
-
demographic characteristics of the service
area and user population;
- economic
characteristics of the service area and user
population;
-
insurance status of the user population;
-
description of services provided;
-
description of professional staff;
-
description of board members;
-
the number and location of all service delivery
sites; and
- completed
Health Center Affiliation Checklist signed
and dated by the Board Chair with copies of
most recent corporate Articles of Incorporation,
bylaws and affiliation agreements if not currently
on file.
3. Completed Forms 2 - 5
4. Updated Tables 1-5 (for each site if applicable).
5. A copy of their most recent audit which includes
a statement of revenues and expenditures for
the audit period and auditor’s letter.
6. Copies of Change in Scope requests approved
during the previous 12 months, under which the
health center added a site(s), decreased existing
sites and/or reduced approved services.
APPENDIX A
EXAMPLE OF A SCHEDULE OF DISCOUNTS
The following is an example of a schedule of
discounts (i.e., charge schedule with a corresponding
discount schedule based on annual income). Applicants
for FQHC Look-Alike designation must submit
a copy of the center’s schedule of discounts
to meet the requirement under the Health Services
section of the FQHC Look-Alike application.
A schedule of discounts must be based on the
most current Department of Health and Human
Services (HHS) Poverty Guidelines. This example,
for the contiguous 48 states and the District
of Columbia, is to be used merely as a guide
and should not be submitted as the schedule
of discounts attachment.
Example:
Based on the Annual Update of the HHS Poverty
Guidelines, Federal Register, February 16, 2001
# |
0
Pay or Minimum Fee |
25%
Fee |
50%
Fee |
75%
Fee |
Full
Fee
More Than |
|
From
|
To |
From |
To |
From
|
To |
From |
To |
1 |
$0. |
$8,590 |
$8,591 |
$11,453 |
$11,454 |
$14,317 |
$14,318 |
17,180 |
$17,180 |
2 |
$0. |
$11,610 |
$11,611 |
$15,480 |
$15,481 |
$19,350 |
$19,351
|
$23,220
|
$23,220 |
3 |
$0. |
$14,630 |
$14,631 |
$19,507 |
$19,508 |
$24,383 |
$24,384 |
$29,260 |
$29,260 |
4 |
$0. |
$17,650 |
$17,651 |
$23,533 |
$23,534 |
$29,417
|
$29,418 |
$35,300
|
$35,300 |
5 |
$0. |
$20,670 |
$20,671 |
$27,560 |
$27,561 |
$34,450 |
$34,451 |
$41,340
|
$41,340
|
6 |
$0. |
$23,690 |
$23,691 |
$31,587
|
$31,588
|
$39,483 |
$39,484
|
$47,380
|
$47,380 |
7 |
$0. |
$26,710 |
$26,711 |
$35,613
|
$35,614 |
$44,517
|
$44,518
|
$53,420
|
$53,420 |
8 |
$0. |
$29,730 |
$29,731 |
$39,640
|
$39,641 |
$49,550 |
$49,551
|
.$59,460
|
$59,460 |
9 |
$0. |
$32,750 |
$32,751
|
$43,667 |
$43,668 |
$54,583 |
$54,584
|
$65,500 |
$65,500 |
10 |
$0. |
$35,770 |
$35,771
|
$47,693
|
$47,694 |
$59,617 |
$59,618
|
$71,540 |
$71,540 |
FORM 1-A
APPLICATION COVER PAGE FOR NEW FQHC DESIGNATION
Applicant’s Legal Name: Medicaid Number:
Address: Medicare Number:
(State) (Zip Code - 9 digit)
Type of Applicant :
Private,
Non-Profit, Public Other
Urban,
Rural
Geographic Area(s) served by the applicant:
Have you applied for FQHC Look-Alike designation
previously ? Yes No
ASSURANCES:
This is to certify that to the best of my knowledge
and belief all data provided in this application
are true and correct. This application for designation
is executed by me as the Authorized Representative
of the organization.
Authorized Representative:
Name:
Title:
Full Address:
(State) (Zip Code - 9 digit)
Telephone: Fax: E-mail:
SIGNATURE: DATE
Notary:
SIGNATURE: DATE
FORM 1-B
ANNUAL RECERTIFICATION APPLICATION COVER PAGE
Applicant’s Legal Name:
Address:
(State) (Zip Code - 9 digit)
Medicaid Number: Medicare Number:
Date of FQHC Designation: No. of sites:
Is the organization currently receiving cost-based
reimbursement? Yes No
If no, please explain.
ASSURANCES:
This is to certify that to the best of my knowledge
and belief all data provided in this application
are true and correct. This application for designation
is executed by me as the Authorized Representative
of the organization.
Authorized Representative:
Name:
Title:
Full Address:
(State) (Zip Code - 9 digit)
Telephone: Fax: E- mail:
SIGNATURE: DATE:
Notary:
SIGNATURE: DATE :
FORM 2.
APPLICATION CHECKLIST
DOCUMENTS TO BE INCLUDED WITH
APPLICATION/RECERTIFICATION
|
ALL
DOCUMENTS MARKED WITH “XX”
MUST BE INCLUDED WITH APPLICATION |
INITIAL
APPLICATION FOR FQHC LOOK-ALIKE STATUS |
RECERTIFICATION
FOR
FQHC LOOK-ALIKE STATUS
|
|
|
|
APPLICATION
PAGE # (s) |
RECERTIFICATION
PAGE # (s) |
|
|
|
|
|
Form
1-A/1-B (as appropriate): Application for
FQHC Designation/ Recertification Cover
Sheet – Notarized |
XX |
|
XX |
|
Table
of Contents |
XX |
|
|
|
Project
Summary |
XX |
|
|
|
Eligibility
Checklist |
XX |
|
XX |
|
|
|
|
|
|
BODY
OF APPLICATION |
XX |
|
* |
|
Need
and Community Impact |
XX |
|
* |
|
Health
Services |
XX |
|
* |
|
Management
and Finance |
XX |
|
* |
|
Governance
|
XX |
|
* |
|
REQUIRED
ATTACHMENTS |
Form
2: Application Checklist |
XX |
|
XX |
|
Form
3: Compliance Checklist |
XX |
|
XX |
|
Form
4: Health Center Affiliation Checklist |
XX |
|
XX |
|
Form
5: Service Sites |
XX |
|
XX |
|
Form
6: Change in Scope Assurances Checklist
|
|
|
XX |
|
Table
1: Services Offered and Delivery Method
|
XX |
|
XX |
|
Table
2, Part A: Users by Age and Gender |
XX |
|
XX |
|
Table
2, Part B: Users by Race/Ethnicity |
XX |
|
XX |
|
Table
2, Part C: Users by Income Levels |
XX |
|
XX |
|
Table
2, Part D: Users by Payment Source |
XX |
|
XX |
|
Table
3: Providers |
XX |
|
XX |
|
Table
4: Patient Service Charges, Collections
and Self-Pay Adjustments |
XX |
|
XX |
|
Table
5: Current Board Member Characteristics
|
XX |
|
XX |
|
Map
of service area identifying site(s), MUAs/MUPs,
and other primary care providers |
XX |
|
XX |
|
Corporate
Bylaws |
XX |
|
XX |
|
Articles
of Incorporation |
XX |
|
XX |
|
Other
contracts as applicable |
XX |
|
XX |
|
Co-Applicant
Agreement (if applicable) |
XX |
|
* |
|
Organization Chart |
XX |
|
* |
|
Job
or Position Description for Key Personnel
|
XX |
|
* |
|
Resumes for Key Personnel |
XX |
|
* |
|
Most recent independent financial audit
including all management letters |
XX |
|
XX |
|
Schedule
of discounts (Sliding Fee Schedule) |
XX |
|
|
|
Current
or requested MUA or MUP designation |
XX |
|
|
|
Current or requested HPSA designation |
XX |
|
|
|
Internal
Revenue Service (IRS) Tax Exempt Certification
for the Applicant, (or
documentation of pending certification)
OR, if the Applicant is a public entity,
the Co - Applicant Board
|
XX |
|
|
|
|
|
|
|
|
*
Update, as necessary, for any changes since
last recertification |
|
|
|
|
FORM 3– Page 1 of 2
COMPLIANCE CHECKLIST
- Is
the applicant organization a non-profit or
public entity?
- Does
the applicant organization demonstrate the
need for primary health care services in the
community(ies) that make up its service area
based on geographic, demographic, and economic
factors?
- Does
the applicant organization serve, in whole
or in part, a designated MUA or MUP?
- Does
the applicant organization have a system of
care that contributes to the availability,
accessibility,
quality, comprehensiveness and coordination
of health services in the service area?
-
Does the applicant organization provide ready
access for all persons to all of the required
primary,
preventive and supplemental health services,
including oral health care, mental health
care and
substance abuse services without regard to
ability to pay either directly on-site or
through established
arrangements?
- Does
the applicant organization provide all additional
health services as appropriate and necessary?
- Does
the applicant organization have patient case
management services (including counseling,
referral
and follow-up services) designed to assist
health center patients in establishing eligibility
for and
gaining access to Federal, State and local
programs that provide or financially support
the provision of
medical, social, educational or other related
services?
-
Does the applicant organization collaborate
appropriately with other health and social
service
providers in their area?
-
Are all contracted services (including management
agreements, administrative services contracts,
etc.)
under the governance, administration, quality
assurance and clinical management policies
of the
applicant organization?
-
Does the applicant organization arrange re
ferrals to providers as may be appropriate
to assure ready
access for all persons to all of the required
primary, preventive and supplemental health
services
without regard to ability to pay?
- Are
all services available to all persons in the
service area or target population regardless
of age,
gender, or the patient’s ability to
pay?
- Does
the applicant organization maintain a core
staff of primary care providers appropriate
for the
population served?
- Are
the primary care providers working at the
health center licensed to practice in the
State where the
center is located?
-
Have all providers been properly credentialed
and privileged according to PINs 99-08 and
2001-11?
- Do
the applicant organization’s physicians
have admitting privileges at their referral
hospital(s), or
other such arrangement to ensure continuity
of care?
- Does
the applicant organization use a charge schedule
with a corresponding discount schedule based
on income for persons between 100 percent
and 200 percent of the Federal poverty level?
- Is/will
the health center be open to provide services
at the times that meet the needs of the majority
of
potential users?
FORM 3 – Page 2 of 2
COMPLIANCE CHECKLIST
-
Does the applicant organization provide professional
coverage during hours when the center is closed?
-
Does the applicant organization have clear
lines of authority from the Board to a chief
executive
(President, Chief Executive Officer or Executive
Director) who delegates, as appropriate, to
other
management and professional staff?
-
Does the applicant organization have systems
which accurately collect and organize data
for reporting
and which support management decision-making
and which integrate clinical, utilization
and financial
information to reflect the operations and
status of the organization as a whole?
-
Does the applicant organization have accounting
and internal control systems appropriate to
the size
and complexity of the organization reflecting
Generally Accepted Accounting Principles (GAAP)
and
separating functions appropriate to organizational
size to safeguard assets?
- Does
the applicant organization maximize revenue
from third party payers and from patients
to the
extent they are able to pay?
-
Does the applicant organization have written
billing, credit and collection policies and
procedures?
-
Does the applicant organization assure that
an annual independent financial audit is performed
in
accordance with Federal audit requirements?
-
Does the applicant organization have a governing
board that is composed or individuals, a majority
of
whom are being served by the organization
and, who as a group, represent the individuals
being
serviced by the center?
-
Does the governing board have at least 9 but
no more than 25 members?
-
Do the applicant organization’s corporate
bylaws demonstrate that the governing board
has the
required authority and responsibility to oversee
the operation of the center?
-
Do the corporate bylaws include provisions
that prohibit conflict of interest or the
appearance of
conflict of interest by board members, employees,
consultants and those who provide services
or
furnish goods to the center?
I certify that the information contained herein
is accurate to the best of my knowledge.
Signature of Governing Board Chairperson
Date
Printed Name
FORM 4 - PAGE 1 OF 3
HEALTH CENTER AFFILIATION CHECKLIST
Organization:
1. Does your organization have, or propose to
establish as part of the new access point application,
any of the following arrangements with another
organization? (NOTE: You must complete a checklist
for each organization with which you have any
of the following arrangements. Copies of all
applicable documents must be included with the
application.)
YES (Please check all that apply and proceed
to question #2)
NO (Go to question #2)
- Contract
for a substantial portion of the approved
scope of project
-
Memorandum of Understanding (MOU)/Agreement
(MOA) for a substantial portion of the approved
scope of project
- Contract
with another organization or individual contract
for core providers
- Contract
with another organization for staffing health
center
-
Contract with another organization for the
Chief Medical Officer (CMO) or Chief Financial
Officer (CFO)
- Merger
with another organization
-
Parent Subsidiary Model arrangement
- Acquisition
by another organization
- Establishment
of a New Entity (e.g., Network corporation)
Name of Affiliating Organization:
Address:
STAFFING
2. The center directly employs the CFO, CMO
and the core staff of full-time primary care
providers. YES NO
3. The center directly employs all non-provider
health center staff. YES NO
If NO in question 2 or 3, the applicant must
submit a request for a good cause exception.
Please see PIN 98-24.
If NO in question 2 or 3, the CEO of the center
retains the authority to select and YES NO
dismiss staff assigned to the center.
(Please
cite reference document and page #.)
FORM 4 - Page 2 of 3
HEALTH CENTER AFFILIATION CHECKLIST
GOVERNANCE:
4.The
Governing Board structure is in compliance with
all requirements YES NO
of section 330 of the Public Health Service
Act.
5. The Governing Board retains its full authorities,
responsibilities and functions as prescribed
in legislation/regulations/BPHC guidelines in
regard to the following as YES NO identified
below.
|
Reference
Document |
Page
# |
|
|
|
-
executive committee function and composition
|
|
|
- selection
of board chairperson
|
|
|
|
|
|
- approval
of the annual budget of the center
|
|
|
- directly
employs, selects/dismisses and evaluates
the Chief Executive Officer (CEO)/Executive
Director
|
|
|
- adoption
of policies and procedures for personnel
and financial management
|
|
|
- establishes
center priorities
|
|
|
- establishes
eligibility requirements for partial
payment of servicesv
|
|
|
- provides
for an independent audit
|
|
|
- evaluation
of center activities
|
|
|
- adoption
of center’s health care policies
including scope and availability of
services, location, hours of operation
and quality of care audit procedures
|
|
|
- establishes
and maintains collaborative relationships
with other health care providers in
the service area
|
|
|
- existence
of a conflict of interest policy
|
|
|
6. The arrangements presented in the affiliation
agreements, as defined in Question 1, do not
compromise the Board authorities or limit its
legislative and regulatory mandated functions
and responsibilities. (Examples of
compromising arrangements are: overriding approval
or veto authority by another entity; dual majority
requirements; super-majority requirements; or
hiring and selection of the CEO). YES NO
FORM 4 - Page 3 of 3
HEALTH CENTER AFFILIATION CHECKLIST
CONTRACTING
7. The center has justified the performance
of the work by a third party. YES NO
(Please cite reference document and page #.)
8. Written affiliation agreement(s) comply with
current Department of Health and Human Services
(HHS) policies, i.e.: YES NO
|
Reference
Document |
Page
# |
- contains
appropriate provisions around the activities
to be performed, time, schedules, the
policies and procedures to be followed
in carrying out the agreement, and the
maximum amount of mo ney for which the
grantee may become liable to the contractor
under the agreement;
|
|
|
-
requires the contractor to maintain
appropriate financial,
program and property management systems
and records in accordance with 45 CFR
Part 74 and provides the center, HHS
and the U.S. Comptroller General with
access to such records;
|
|
|
- requires
the submission of financial and programmatic
reports to the health center;
|
|
|
- complies
with Federal procurement standards or
grant requirements including conflict
of interest standards;
|
|
|
-
is subject to termination (with administrative,
contractual and legal remedies) in the
event of breach by the contractor.
|
|
|
PLEASE INCLUDE LIST AND COPIES OF ALL
RELEVANT AND CITED DOCUMENTS
I certify that the information contained herein
is accurate to the best of my knowledge.
Signature of Governing Board Chairperson
Date
Printed Name
FORM 5
SERVICE SITES
Sites to be included in designation: (Tables
1 – 5 must be included for each site if
possible.)
Each site must be discussed in the narrative
of the application.
Site # 1
Name: Urban Rural
Address:
(State) (Zip Code - 9 digit)
Phone: Fax:
Site # 2
Name: Urban Rural
Address:
(State) (Zip Code - 9 digit)
Phone: Fax:
Site # 3
Name: Urban Rural
Address:
(State) (Zip Code - 9 digit)
Phone: Fax:
Add additional pages if necessary
FORM 6
CHANGE IN SCOPE ASSURANCES CHECKLIST
1. The Board has approved the change in scope.
Yes No Documentation: Board minutes dated
2. The health center organization will continue
to serve a Medically Underserved Area or Medically
Underserved Population. Yes No
3. The change in scope will maintain or improve
access to primary and/or preventive care for
the
underserved population. Yes No
4. The change in scope will maintain or improve
the appropriateness of care, quality of care,
and
outcomes. Yes No
5. The health center will offer discounts to
individuals with incomes below 200 percent of
poverty level
at the new site or for the new service, as applicable,
and services will be provided regardless of
patients’ ability to pay. Yes No
6. The change in scope will not reduce the scope
of primary care services offered to the target
population or the total number of patients seen.
Yes No
7. If added sites(s) have a different service
area and/or target population than those already
being served,
board representation will be modified to represent
users of those added or relocated sites. Yes
No N/A
8. If added sites(s) are serving the same target
population and/or the same service area as another
FQHC,
efforts have been made to collaborate on this
specific change. Yes No N/A
9. The change in Scope will be fully compliant
with section 330-related requirements and BPHC
Program Expectations. Yes No N/A
*If you answered “No” to any of
the assurances, briefly explain and discuss
any relevant factors (attach
additional pages, if necessary):
To the best of my knowledge, I assure that the
above information is true and correct.
Signature:
Name:
Date:
TABLE 1
SERVICES OFFERED AND DELIVERY METHOD
Service
Type |
Provided
by Site
(a) |
By
Referral
or Contract
Site Pays*
(b) |
By
Referral
or Contract
No Pymt
(c) |
Not
Provided
(d)
|
Medical
Care Services |
1.
General Primary Medical Care (other than
below) |
|
|
|
|
2.Diagnostic
Laboratory (technical component) |
|
|
|
|
3.
Diagnostic X-Ray (technical component) |
|
|
|
|
4.
Diagnostic Tests/Screenings (professional
comp.) |
|
|
|
|
5.
Emergency Medical Services |
|
|
|
|
6.
Urgent Medical Care |
|
|
|
|
7.
24-hour Coverage Other Professional Services |
|
|
|
|
8.
Family Planning |
|
|
|
|
9.
HIV Testing |
|
|
|
|
10.
Immunizations |
|
|
|
|
11.
Following Hospitalized Patients |
|
|
|
|
Obstetrical
and Gynecological Care |
12.
Gynecological Care |
|
|
|
|
13.
Prenatal Care |
|
|
|
|
14.
Antepartum Fetal Assessment |
|
|
|
|
15.
Ultrasound |
|
|
|
|
16.
Genetic Counseling and Testing |
|
|
|
|
17.
Amniocentesis |
|
|
|
|
18.
Labor and Delivery Professional Care |
|
|
|
|
19.
Postpartum Care |
|
|
|
|
Speciality
Medical Care |
20.
Directly Observed TB Therapy |
|
|
|
|
21.
Other Specialty Care |
|
|
|
|
22.
Dental Care – Preventive |
|
|
|
|
23.
Dental Care – Restorative |
|
|
|
|
Service
Type |
Provided
by Site
(a) |
By
Referral
or Contract
Site Pays*
(b) |
By
Referral
or Contract
No Pymt
(c) |
Not
Provided
(d)
|
Mental
Health / Substance Abuse Services |
25.
Mental Health Treatment/Counseling |
|
|
|
|
26.
Developmental Screening |
|
|
|
|
27.
24-hour Crisis Intervention/Counseling |
|
|
|
|
28.
Other Mental Health Services |
|
|
|
|
29.
Substance Abuse Treatment/Counseling |
|
|
|
|
30.
Other Substance Abuse Services |
|
|
|
|
Other
Professional Services |
31.
Hearing Screening |
|
|
|
|
32.
Nutrition Services other than WIC |
|
|
|
|
33. Occupational or Vocational Therapy |
|
|
|
|
34.
Physical Therapy |
|
|
|
|
35.
Pharmacy |
|
|
|
|
36.
Vision Screening |
|
|
|
|
37.
WIC Services |
|
|
|
|
38.
Case Management |
|
|
|
|
Other
Services |
39.
Child Care (during visit to Site) |
|
|
|
|
40.
Discharge Planning |
|
|
|
|
41.
Eligibility Assistance |
|
|
|
|
42. Employment/Educational Counseling |
|
|
|
|
43.
Environmental Hlth Risk Redctn (via Detectn) |
|
|
|
|
44.
Food Bank / Delivered Meals |
|
|
|
|
45.
Health Education |
|
|
|
|
46.
Housing Assistance |
|
|
|
|
47.
Interpretation/Translation Services |
|
|
|
|
48.
Nursing Home & Assisted Living Placement
Dental Care Services |
|
|
|
|
49.
Outreach |
|
|
|
|
50.
Transportation |
|
|
|
|
51.
Home Visiting |
|
|
|
|
52.
Parenting Education |
|
|
|
|
53.
Other (Specify: ) |
|
|
|
|
* Copies of all contracts and agreements for
referral and contracted services paid for by
the site should be included in the application.
TABLE 2 – PART A
USERS BY AGE AND GENDER
Age
Groups |
Male
Users |
Female
Users |
Prenatal
Users |
1.
Under age 1 |
|
|
|
2.
Ages 1-4 |
|
|
|
3. Ages 5-12 |
|
|
|
4.
Ages 13-14 |
|
|
|
5.
Ages 15-19 |
|
|
|
6.
Ages 20-24 |
|
|
|
7.
Ages 25-44 |
|
|
|
8.
Ages 45-64 |
|
|
|
9.
Ages 65-74 |
|
|
|
10.
Ages 75-84 |
|
|
|
11.
Ages 85 and over |
|
|
|
12.
Total Users |
|
|
|
TABLE 2 - PART B
USERS BY RACE/ETHNICITY
Race/Ethnicity/Language
|
Number
of Users |
Number
in
Service Area |
1.
Asian |
|
|
2.
American Indian or Alaska Native |
|
|
3.
Black or African American |
|
|
4.
Native Hawaiian or Other Pacific Islander |
|
|
5.
White |
|
|
6.
Hispanic or Latino |
|
|
7.
Unreported/Unknown |
|
|
8.
Total Users |
|
|
9. Users Needing Interpretation Services |
|
|
TABLE 2 - PART C
USERS BY INCOME LEVELS
Percent
of Poverty Level |
Number
of Users |
Number
in
Service Area |
1.
100% and below |
|
|
2. 101 - 200% |
|
|
3.
Above 200% |
|
|
4.
Unreported/Unknown |
|
|
5.
Total Users |
|
|
TABLE 2 - PART D
USERS BY PAYMENT SOURCE
Payment
Sources |
Number
of Users |
Number
in
Service Area |
1.
Medicare |
|
|
2. Medicaid |
|
|
3.
Other Public Insurance |
|
|
4.
Other Third Parties |
|
|
5.
Self-Pay |
|
|
6.
Total Users |
|
100% |
TABLE
3
PROVIDERS
Personnel
by Major Service Categories |
Total
FTEs |
Status
(Place “X” if
Employed directly;
“C” if by contract) |
State
License
(Y/N) |
Hospital
Admitting
Privileges
(Y/N) |
Board
Certified
(Y/N)
|
Total
Encounters |
Medical
Providers
(i.e., General Practitioners,
Internists, Obstetrician/Gynecologists,
Pediatricians, Other Physician Specialists,
Nurse Practitioners, Certified Nurse Mid-Wives) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Dental
Providers
(i.e., Dentists, Dental Hygienists) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Mental
Health & Substance Abuse Providers
(i.e., Psychiatrists, other specialists) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Add additional pages as necessary
TABLE 4
PATIENT SERVICE CHARGES, COLLECTIONS, AND SELF-PAY
ADJUSTMENTS
Payment
Source
|
Full
Charges |
Amount
Collected |
Adjustments |
Medicare |
1.
Medicare Fee-for-Service |
|
|
|
2.
Medicare Capitated |
|
|
|
3.
Total Medicare (Lines 1 and 2) |
|
|
|
Medicaid |
4. Medicaid Fee-for-Service |
|
|
|
5.
Medicaid Capitated |
|
|
|
6.
Total Medicaid (Lines 4 and 5) |
|
|
|
Other Public Payers |
7.
Other Public Fee-for-Service |
|
|
|
8.
Other Public Capitated |
|
|
|
9.
Total Other Public (Lines 7 and 8) |
|
|
|
Other
Third Party |
10.
Other Third Party Fee-for-Service |
|
|
|
11.
Other Third Party Capitated |
|
|
|
12. Total Other Third Party (Lines 10 and
11) |
|
|
|
Self-Pay |
13.
Self-Pay |
|
|
|
14.
Total (Lines 3, 6, 9, 12, and 13)
Self-Pay Adjustment Type |
|
|
|
15.
Self-Pay Sliding Fee Adjustments |
|
|
|
16.
Other Self-Pay Adjustments (Self-Pay Bad
Debt and Charity Care) |
|
|
|
17.
Total Self-Pay Adjustments (Lines 15 and
16) |
|
|
|
TABLE 5
CURRENT BOARD MEMBER CHARACTERISTICS
Total Number/Range of Members Established in
By-Laws or Articles of Incorporation: Positions
Filled: as of:
Name |
Board
Office Held |
User
Status
(Y/N) |
Area
of Expertise |
Live
(L) or Work (W) in Service Area |
Years
of
Continued
Board Service |
1. |
|
|
|
|
|
2. |
|
|
|
|
|
3. |
|
|
|
|
|
4. |
|
|
|
|
|
5. |
|
|
|
|
|
6. |
|
|
|
|
|
7. |
|
|
|
|
|
8. |
|
|
|
|
|
9. |
|
|
|
|
|
10. |
|
|
|
|
|
Indicate # Board Members by Sex: F = M =
Indicate # Board Members by Race/Ethnicity:
White: Hispanic or Latino: Black/African American:
Asian/Pacific Islander:
American Indian & Alaska Native:
Notes:
- Use
additional pages if necessary.
-
If board member is not a user (i.e., "N"
in column 3) indicate if that member derives
more than 10% of his/her income from the health
care industry (e.g., “N > 10%”
or “N < 10%”).
-
Migrant/Seasonal Farmworkers should be noted
under Area of Expertise, and should reflect
a
reasonable proportion to their share of the
user population.
|