Look-Alike Overview and Initial Designation Application Process

U.S. Department of Health and Human ServicesHealth Resources and Services Administration

Bureau of Primary Health Care

February 13, 2013

Agenda

• Health Center, Look-Alike and FQHC Overview• Changes from 2011/2012 Instructions• Eligibility Requirements• Need, Target Population, and Service Area• Operational and Compliant at the Time of

Application• Services• Contracts/Written Agreements• Application Process, Components and Submission • Preparing a Successful Application• Questions and Answers

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What is a Look-Alike?

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GranteesLook-alikes

FQHCs: All health centers in the Health Center Program are eligible to apply to be reimbursed using specific Federally Qualified Health Center (FQHC) payment methodologies.

Tribal Organizatio

ns

Look-alikes are health centers that don’t receive a grant

Health CentersHealth Center Program

What is an FQHC?

A Federally Qualified Health Center (FQHC) is an entity defined under Medicare and Medicaid statutes.* The term “FQHC” is used by CMS to indicate eligibility for reimbursement by Medicare, Medicaid, and CHIP using specific payment methodologies. To be an FQHC, an entity must fall under at least one of the following categories: • Meet requirements of the Health Center Program and

receive a grant under section 330 of the Public Health Service Act.

• Meet requirements of the Health Center Program but do not receive a grant under section 330 of the Public Health Service Act.

• Organizations that qualify as an outpatient health program or facility operated by a tribe or tribal organization.**

* Social Security Act §1861(aa)(4)(B) and §1905(l)(2)(B). ** Under the Indian Self-Determination Act or by an Indian organization receiving funds under Title V of the Indian Health Care Improvement Act.

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Fundamental Principles of Health Centers

• Private non-profit or public entities that serve a high-need community or population.

• Governed by a community board; at least a majority must be health center patients who represent the patient population served.

• Provide comprehensive primary medical care and enabling and supporting services as their primary purpose.

• Provide services to all, with fees adjusted based upon ability to pay.

• Collaborate with safety net providers and others (e.g., State and local health departments) in the area.

• Meet all performance and accountability requirements for administrative, clinical and financial operations.

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Benefits

Benefit Applicable to Look-Alikes

Health Center Program grant funding NO

Eligible to apply for Medicaid FQHC Payment Methodologies (Prospective Payment Systems [PPS])

YES

Eligible to apply for Medicare FQHC Payment Methodologies

YES

Access to 340B drug pricing YES

Eligible for Federal Tort Claims Act medical malpractice insurance

NO

Automatic Health Professional Shortage Area (HPSA) Designation

YES

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Highlights of 2013 Changes

• Guidance for Annual Certification and Renewal of Designation applications will be released separately.

• HRSA has final authority to designate new and recertify existing look-alikes and to approve change in scope requests. – The Centers for Medicare and Medicaid Services (CMS) will continue to

have authority over FQHC payment methodologies and FQHC provider enrollment processes.

• Applicants must demonstrate the organization has been operational for a minimum of 6 months prior to application submission.

• Applicants must document that primary medical care is the organization’s primary purpose.

• Applicants must document that it operates at least one full-time, permanent site. 7

Look-Alike Eligibility Requirements

Eligibility Requirements

Must be a private, charitable, tax-exempt nonprofit organization OR public entity (direct or co-applicant arrangement).

Must serve a currently designated medically underserved area (MUA) or medically underserved population (MUP).

Must demonstrate that the organization is not owned, controlled or operated by another entity.

Have at least one full-time permanent service delivery site operating at least 40 hours per week.

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Look-Alike Eligibility Requirements (continued)

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Eligibility Requirement

Must be operational for at least six months prior to application.

The primary purpose of the applicant organization must be to provide primary medical care.

Applicants must be compliant with all Health Center Program requirements at the time of application.

Documenting Operational Status

Applicants must provide the following evidence of operational status:• At least 6 months of governing board

meeting minutes, demonstrating a compliant board that meets monthly and exercises its required authorities over an operating health center.

• An independent financial audit or at least 6 months of financial statements that provide sufficient information for the board to exercise associated decision making and which reflect the organizational structure for which look-alike designation is requested.

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Documenting Operational Status (continued)

• Billing to Medicaid and Medicare for primary care visits and documentation of current primary care provider numbers.

• Billing for primary care services using a compliant sliding fee discount scale.

The operational period may include time during which the organization is coming into compliance with Health Center Program requirements (e.g., part of the 6 months may include finalizing contracts or formal referral arrangements for required services).

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Compliance at the Time of Application

Applicant must demonstrate full compliance with Health Center Program requirements, at the time of application.

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1 Need 11 Collaborative Relationships

2 Required and Additional Services 12 Financial Management and Control Policies

3 Staffing 13 Billing and Collections4 Accessible Hours of

Operation/Locations14 Budget

5 After Hours Coverage 15 Program Data Reporting Systems6 Hospital Admitting Privileges and

Continuum of Care16 Scope of Project

7 Sliding Fee Discounts 17 Board Authority8 Quality Improvement/Assurance Plan 18 Board Composition

9 Key Management Staff 19 Conflict of Interest Policy

10 Contractual/Affiliation Agreements

Primary Purpose is Primary Medical Care

• Primary medical care patient visits for current and projected patients must be at least 50% of the combined visits for all services provided.

• Primary medical services include basic health services related to family medicine, internal medicine, pediatrics, obstetrics, or gynecology that are furnished by physicians or, where appropriate, mid-level providers.

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Need for Services

Applicants must demonstrate there is sufficient need in the proposed service area to support a new health center. In addition to the conducting a needs assessment and completing the Need for Assistance Worksheet, applicants must:• Define a logical service area based on need and

organizational capacity.• Produce a service area map using HRSA’s UDS

Mapper and provide data from the UDS Mapper to support the need for services in the proposed service area. http://www.udsmapper.org/tutorials.cfm 14

Service Area

• The service area is the area in which the majority of the organization’s patients reside. When defining a service area, applicants must ensure the following:– Services provided are available and accessible to the

residents of the area;

– Boundaries of the area conform, to the extent practicable, to relevant boundaries of political subdivisions, school districts, and Federal and State health and social service programs; and

– Boundaries eliminate, to the extent possible, barriers to access to the services of the center, including barriers resulting from the area’s physical characteristics, its residential patterns, its economic and social grouping, and available transportation.

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Target Population

• A target population is the population to whom the look-alike targets its services. The target population may be a subset of the service area, e.g., all low income residents in the service area, or it may include all residents of the service area, as appropriate.

Services must be available to all residents of the service area without regard for ability to pay.

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Required Services Overview

• Services Provided Directly by Applicant (Form 5A, Column 1)– Applicant provides the services directly.

• Services Provided via a Formal Written Contract/Agreement (Form 5A, Column 2)– Applicant pays (and bills) for services provided by

individual providers or a provider group under a formal contract/agreement.

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Services included in the scope of project must be available equally to all, regardless of ability to pay.

Required Services Overview(continued)

• Formal Written Referral Arrangement/Agreement (Form 5A, Column 3) – Applicant maintains responsibility for the patient’s

treatment plan and provides all required preventive, enabling, and additional health services as appropriate and necessary.

– The applicant does not pay or bill for the service.

– Applicant must describe:• How visits will be documented in the patient record;

• How follow-up care will be assured; and

• How services will be provided on a sliding fee discount scale.18

Specialty and Other Services

• Applicants may not include specialty and other services in the initial designation scope of project.

• Specialty and other services may be added to the scope of project through a Change in Scope request after look-alike designation.

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Documenting Contracts and Agreements

Attachment 7—Contracts and Affiliation Agreements

– Comprehensive account of each contract, agreement and formal referral arrangement.

Form 8—Health Center Agreements– All agreements that constitute a substantial

portion of the proposed scope of project.– Applicants must attach all contracts in full and

summarize them in Attachment 7.

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Application Process

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Application Process: Grantee and Look-Alike Comparison

Grantee Look-AlikeCompetitive Not competitiveAnnounced application deadlines

Rolling

Submitted application is final May have the opportunity to provide additional information

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Initial Designation Application Preparation: One Example

Assess need for additional primary care services in

the community

Operate as a primary care provider under governing board’s authority and establish compliance with all

Health Center Program Requirements

(6 months prior to application submission)

Demonstrate full compliance with all Health Center Program requirements

Submit initial designation application

Address look-alike eligibility

requirements as needed

Establish a compliant governing

board

Collaboratively explore options to address

unmet needs

Develop coordinated

plan to establish a new look-

alike

Application Review Process

Initial Designatio

n Application

*

HRSA completenes

s and eligibilityreview

Disapproval and TA

HRSA reviews for compliance with all Health Center Program requirements

Request for

additional informatio

n

Disapproval

HRSA issues Notice of Look-Alike Designation

(NLD)

Newly designated look-alike applies to CMS and State Medicaid agency for FQHC

reimbursement and for other benefits (e.g., 340B drug pricing), as appropriate

*Applications must be responsive to the most current Look-Alike Initial Designation Instructions. HRSA will not review applications that are not responsive to the specific requirements for look-alike designation.

Additional informatio

n submissio

n

Allotted Time for Application Review

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Responsible Entity

Step in Process Number of Days

Applicant Development and submission of application once the application process has been initiated in the EHB.

90

HRSA Initial review of the application once received in the EHB.

90

Applicant Response to additional information requested by HRSA (as necessary).

5-30

HRSA HRSA review of applicant response to additional information and issuance of Notice of Look-Alike Designation or Disapproval.

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HRSA timeframes are approximate and may vary due to extenuating issues.

Enrolling for FQHC Medicare and Medicaid Reimbursement

• Look-alike designation establishes eligibility to enroll in Medicare as an FQHC and for enrollment in State Medicaid program as an FQHC provider.

• Each new look-alike organization should:– Prepare and submit a Medicare enrollment

application for each permanent and seasonal site and receive appropriate approvals prior to billing under the FQHC benefit.

– Enroll in the state Medicaid program as an FQHC provider.

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Application Components

• Program Abstract • Program Narrative

– Need– Response – Collaboration– Evaluative measures– Resources/capabilities– Governance

• Forms • Other Attachments

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Required FormsForm 1A: General Information WorksheetClinical Performance MeasuresFinancial Performance MeasuresForm 2: Staffing ProfileForm 3: Income Analysis FormForm 3A: Look-Alike BudgetForm 4: Community Characteristics Form 5A: Services Provided Form 5B: Service Sites Form 5C: Other Activities/Locations (if applicable)Form 6A: Current Board Member Characteristics Form 6B: Request for Waiver of Governance Requirements Form 8: Health Center AgreementsForm 9: Need for AssistanceForm 10: Annual Emergency Preparedness and Management Report Form 12: Contact Information

MS Word versions of all forms are located at http://bphc.hrsa.gov/about/lookalike.

These forms can be used for planning purposes . However, forms submitted as part of the official application must be completed in the EHB.

Required Attachments

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

Application Submission

• Applications must be submitted through the HRSA EHB– Refer to HRSA’s Electronic Submission User Guide,

available online at http://bphc.hrsa.gov/about/lookalike/index.html for detailed application and submission instructions.

• Applicants have a maximum of 90 calendar days to complete an application in the EHB system.

• HRSA will not review ineligible applications or applications not submitted within 90 calendar days.

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Preparing a Successful Application

• Follow all look-alike initial designation application instructions for the Project Narrative and for each required form and attachment.

• Ensure that information is consistent across forms, attachments, and the Project Narrative.

• Demonstrate clearly and thoroughly how the organization has been operational (e.g., providing primary health care services in its current organizational structure, under a compliant governing board) for at least 6 months.

• Demonstrate clearly and thoroughly how the organization currently meets all Health Center Program requirements. Program requirements are located at http://bphc.hrsa.gov/about/requirements/index.html.

Preparing a Successful Application(continued)

• Ensure that all contracts and affiliation agreements comply with HRSA policy. http://bphc.hrsa.gov/policiesregulations/policies/governance.html

• Develop time-framed and realistic clinical and financial performance measure goals. http://bphc.hrsa.gov/policiesregulations/performancemeasures/index.html

• Identify a logical service area based on need. Provide a service area map using HRSA’s UDS Mapper and indicate the locations of all other safety net providers. – See http://www.udsmapper.org/tutorials.cfm and go to

How to Create a Service Area Map and Data Table

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Preparing a Successful Application

• Request assistance from your primary care association, state primary care office, and other HRSA partners. A list of HRSA partners is located at: http://bphc.hrsa.gov/technicalassistance/partnerlinks/

• Consult BPHC Policy Information Notices (PINs) and Program Assistance Letters (PALs) for guidance as needed. PINs and PALs are located at: http://bphc.hrsa.gov/policiesregulations/policies/index.html.

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• Pursue collaboration with all health centers (grantees and look-alikes) and other safety net providers in and adjoining your service area.

• Consult PIN 2007-09: Service Area Overlap, Policy and Process located at: http://bphc.hrsa.gov/policiesregulations/policies/pin200709.html.

• Provide letters of support from health centers and others (e.g., other safety net providers, State and local health departments) in your service area.

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Questions

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Technical Assistance

HRSA Partner Links (Primary Care Associations, Primary Care Offices, National

Cooperative Agreements)http://bphc.hrsa.gov/technicalassistance/partnerlinks/index.html

Office of Policy and Program Development Instructions and TA: http://

bphc.hrsa.gov/about/lookalike/ E-mail: lookalike@hrsa.gov Telephone: (301) 594-4300

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