HRSA’s September 3, 2014 Weekly Digest Includes Clarifications Regarding HRSA’s Role in Monitoring

On September 3, 2014, the weekly HRSA Primary Health Care Digest included two clarifications regarding HRSA’s role in financial and programmatic monitoring. With respect to the former, HRSA will no longer require submission of Financial Recovery Plans as the formal monitoring of financial performance. HRSA stressed that while it will continue to assess health center compliance with financial management requirements (including submission of an annual audit), it believes that financial viability is an individual health center responsibility. As for the latter, HRSA also addressed the reduction of health center grants for projects that fail to meet the proposed patient projections upon which the grant amounts were based. The reduction of funds was first addressed in the FY 2015 Service Area Competition (SAC) applications, as summarized in this Policy Shop blog from earlier this year. In this regard, HRSA will no longer impose grant conditions when health centers do not meet patient projections – going forward, a reduction in funds through the SAC process will be the remedy for failure to meet projections.

Effectively, these changes to internal policies indicate a shift by HRSA to hold health centers to a greater level of individual health center accountability by eliminating certain interim steps for non-compliance findings. Previously, both financial recovery plans and conditions for not meeting patient projections would have been considered interim measures that could be taken in lieu of and prior to more severe sanctions (potential de-funding / re-competition of existing grants and reduction of grant amounts, respectively). These actions appear to align with the approach taken by HRSA in Policy Information Notice (PIN) 2013-01: Health Center Budgeting and Accounting Requirements, in which HRSA indicated that use of non-grant funds was an individual health center responsibility (rather than subject to HRSA control), provided that expenditures comply with the statutory limitations set forth in Section 330. Further, these actions are consistent with an overall “hands-off” approach discussed by HRSA management during the recent NACHC Community Health Institute – shifting responsibility for individual projects from HRSA to the programs themselves.

To assist with best practices in financial planning and in establishing patient projections, HRSA suggests that health centers contact their State and Regional Primary Care Associations and National Cooperative Agreement organizations. Please do not hesitate to contact NACHC or your PCA is you have any questions regarding these issues.

HRSA issues PAL on Updated Change in Scope Process

On August 28, 2014, HRSA issued Program Assistance Letter #2014-10: Updated Process for Change in Scope Submission, Review and Approval Timelines. The PAL expands on clarifications in PAL 2013-03, issued last year, and applies to both grantees and FQHC look-alike entities. Specifically, the PAL clarifies the following timelines:

  • Submission of Complete Change in Scope (CIS) Requests. Health centers should submit complete CIS requests (i.e., requests that include all information requested by HRSA) at least sixty (60) days prior to the desired implementation date. HRSA will notify the health center of its final decision within sixty (60) days of receiving a complete request.
  • Requests for Additional Information. If necessary for evaluation of the CIS request, HRSA may request additional or clarifying information through a “Change Request” in the EHB. In those cases, HRSA may extend the review process beyond the sixty (60) day time frame to account for the time necessary for the health center to submit, and for HRSA to review, the additional information.
  • Other Review Process Extensions. HRSA also may extend the sixty (60) day review if additional analysis is necessary, regardless of whether additional information is submitted. Examples include situations that require a service area overlap analysis.
  • Deactivation of Inactive CIS Request. If a CIS submission is initiated but not completed by the grantee within sixty (60) days or if the health center does not respond to a request for additional information within sixty (60) days of the request, HRSA will “deactivate” the CIS request. If the health center wants to proceed with the request, it will be required to submit a new CIS request.

In a change from existing policy, the effective date for a CIS will no longer reflect the date that a complete request was received by HRSA. Rather, the effective date will be the date that BPHC recommends approval of the CIS request. Grantees will receive a Notice of Award approving the CIS, while FQHC look-alikes will receive notification of the approval via the EHB. If the request is not approved, HRSA will inform the health enter via EHB notification.

Finally, the PAL reflects existing policy regarding implementation – health centers are required to implement an approved CIS after the effective date but within 120-days of receiving approval and must verify through the EHB that such implementation took place. HRSA emphasizes that the verification step must be completes to be officially documented in the health center’s scope of project.

Please do not hesitate to contact us should you have any questions on this or any other issues.

Are You Ready? NACHC Offering Trainings on Medicare FQHC PPS

As you all know, CMS published a final rule on the Medicare Prospective Payment System for Federally Qualified Health Centers (FQHCs) as mandated by the Affordable Care Act. The final rule is estimated to increase the ability and capacity of FQHCs to provide essential and affordable services by increasing Medicare payments.

The new payment system will be implemented beginning on October 1, 2014. FQHCs will be transitioned to the new payment system throughout 2015.

Are you ready for these changes? It is essential that you implement these changes correctly the first time as the stakes are extremely high!

Have you considered these factors for the implementation process?

  1. If you implement the new Medicare PPS rule correctly, your health center stands to increase its revenue substantially.
  2. If you implement incorrectly, you risk not only leaving money on the table, but also scrutiny from CMS for setting your rates too high (or too low).
  3. This rule has significant impact on your grant – particularly as to how your sliding fee scale is applied to patients. All Health Centers must understand and prepare for these changes.

It is important to implement the new Medicare PPS rule correctly the FIRST time!

To assist you with this process, NACHC has developed a one-day hands-on training that will assist you with this process with the first training scheduled for September 3 and 4 in Chicago, IL.

It is not too late to register for the September 3 or 4 session in Chicago, IL and implement correctly on October 1!


HRSA Issues Revised and Updated FTCA Manual

On July 21, 2014, HRSA issued a new Federal Tort Claims Act: Health Center Policy Manual – which updates and supersedes the prior manual (PIN 2011-01), as well as a Program Assistance Letter (PAL) explaining the updates and modifications (PAL 2014-09). The new updated manual reflects an expansion in Federal Tort Claims Act (FTCA) coverage for certain services provided to non-health center patients, which was published as a final rule in the Federal Register on September 23, 2013.

Specifically, Sub-section I.C.4 of the manual expands FTCA coverage to include services provided to non-health center patients experiencing certain individual emergencies, provided that the health center provider is furnishing (or is about to furnish) FTCA covered services within the center’s scope of project and is asked to temporarily assist in an individual emergency situation at or near the provider’s location. This could include, for example, situations under which a health center provider is rounding a hospitalized health center patient and asked to assist with an emergency occurring with another inpatient who is not a health center patient. To be eligible for coverage, HRSA requires the health center to have documentation verifying that the provision of such individual emergency treatment is a condition of the provider’s employment at the health center. According to the manual, documentation could include “employee manual provisions, health center bylaws, or an employee contract.”

Sub-section I.C.4 also clarifies that: (1) FTCA coverage is available when, on behalf of the health center, a health center provider conducts or participates in health fairs and immunization campaigns (previously, coverage was available when the health center conducted those activities directly but it was unclear whether FTCA extended to participation in a health fair or immunization campaign conducted by another organization); and (2) the covered immunization campaigns include immunizations provided to both children / adolescents and adults. Both of these clarifications were published in the September 2013 final rule and update prior policy published in the Federal Register in 1995.

Finally, the new manual updates certain links and contact information. Specific updates include the following:

Sub-section I.G. The Deeming Application Process: provides an updated link to information on deeming applications.
Sub-section II.J. Overview of Claims Filings & Section III Appendix: provides updated contact information for the General Law Division within the Office of the General Counsel of the Department of Health and Human Services.
Endnotes 6 and 9: provide updated links to the Bureau of Primary Health Care Policy Website

Court of Appeals Rulings Don’t “Blow Up” the ACA

By Dashawn Groves

On June 22, 2014, two U.S. courts of appeals issued conflicting rulings on whether the health insurance subsidies are available to ONLY people in states that have created their own exchanges or to all residents regardless if the exchange was created by the state or federal government. The cases center on a brief description in the Affordable Care Act (ACA) that says subsidies will be available “through an exchange established by the State.”  The Internal Revenue Service (IRS) interpreted the law to allow individuals to receive subsidies to help purchase insurance, regardless of whether they are in an exchange run by their state or by the federal government. Opponents are questioning the interpretation of the law, saying that subsidies are only available to individuals residing in the 14 states with state-based exchanges.
What does it mean for health centers and their patients?
Neither case will have an immediate impact on the ACA as it could take years for the courts to decide. Individuals across the country will continue to receive the ACA’s tax credits and subsidies, ensuring they can afford the health care they need. Health center O&E staff should continue to do business as usual, reaching out to individuals and enrolling them in Medicaid, CHIP and the Marketplace. Current subsidies would likely remain in place until there is a final legal decision on the matter.
What did the Courts decide?
The U.S. Court of Appeals for the District of Columbia was the first ruling (Halbig v. Burwell) out last week. In a 2-1 decision, the three-judge panel ruled that the health insurance subsidies were only available to the individuals in the 14 states and the District of Columbia operating their own health insurance exchanges. The majority opinion concluded “that the ACA unambiguously restricts” the subsidies to “exchanges ‘established by the state.’ “ The dissenting opinion argues, “it was well understood that without the subsidies, the individual mandate was not viable as a mechanism for creating a stable insurance market.”

Shortly following the Halbig v. Burwell ruling, a three-judge panel on the Fourth Circuit Court of Appeals in Richmond, VA unanimously ruled in King v. Burwell that the subsidies were available to residents in all states.  Similar to the dissenting opinion in Halbig v. Burwell, the Fourth Circuit concluded that “established by the State” is ambiguous, when read in combination with another section of the ACA, and could include federal exchanges.  The “broad policy goals of the Act,” described above, primarily persuaded the court that the IRS’s interpretation of the statute was permissible.
What happens next?
The two decisions are not the final word.  All 11 judges on the D.C. Circuit Court could be asked to decide the Halbig v. Burwell case, a process called “en banc” review.  The Obama administration has said it will ask the court for such a review.  A majority of the judges would have to agree to rehear the case for it to be reconsidered in this way.  The challengers in King v. Burwell could ask the Fourth Circuit to reconsider as well.  Two trial court cases raise similar issues, one in Oklahoma and one in Indiana.  Those cases could also go to appellate courts. Oklahoma is in the 10th Circuit; Indiana is in the 7th.  Depending on the outcomes of the various rulings, all the courts could end up agreeing, or there could remain a disagreement between different circuits.  Either side could appeal the rulings to the Supreme Court for consideration. It is unclear when a final decision will be made.