Look-Alike Overview and Initial Designation Application Process

1. Look-Alike Overview and Initial Designation Application Process U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Primary Health Care February 13, 2013

2. 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

3. What is a Look-Alike? Health Center Program Health Centers Look-alikes are health centers that don’t receive a grant Tribal Organizations 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.

4. 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.

5. 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.

6. Benefits

7. 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.

8. Look-Alike Eligibility Requirements

9. Look-Alike Eligibility Requirements (continued) Applicants must be compliant with all Health Center Program requirements at the time of application.

10. 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 statementsthat provide sufficient information for the board to exercise associated decision making and which reflect the organizational structure for which look-alike designation is requested.

11. Documenting Operational Status (continued) • Billing to Medicaid and Medicarefor primary care visits and documentation of current primary care provider numbers. • Billingfor 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).

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

13. 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.

14. 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

15. 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.

16. 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.

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

18. 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 notpay 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.

19. 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.

20. 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.

21. Application Process

22. Application Process: Grantee and Look-Alike Comparison

23. Initial Designation Application Preparation: One Example Develop coordinated plan to establish a new look-alike Address look-alike eligibility requirements as needed Assess need for additional primary care services in the community Collaboratively explore options to address unmet needs 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) Establish a compliant governing board Submit initial designation application Demonstrate full compliance with all Health Center Program requirements

24. Application Review Process Request for additional information Additional information submission Disapproval Disapproval and TA HRSA completeness and eligibility review Initial Designation Application* HRSA reviews for compliance with all Health Center Program requirements 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 HRSA issues Notice of Look-Alike Designation (NLD) *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.

25. Allotted Time for Application Review HRSA timeframes are approximate and may vary due to extenuating issues.

26. 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.

27. Application Components • Program Abstract • Program Narrative • Need • Response • Collaboration • Evaluative measures • Resources/capabilities • Governance • Forms • Other Attachments

28. Required Forms 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.

29. Required Attachments

30. 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.

31. 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.

32. 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.cfmand go to How to Create a Service Area Map and Data Table

33. 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.

34. 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.

35. Questions

36. 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