(Medicare Benefit Policy Manual)

For inform ation on claims processing, see Pub. 100- 04, Medicare Claims Processing  Manual, chapter 9, http://www.cms.gov/Regulations -and- Guidance/Guidance/Manuals/downloads/clm104c09.pdf    For information on certification requirements, see Pub. 100-07, State Operations Manual, Chapter 2, and Appendix G, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c02.pdf    10.2 - FQHC General Information  (Rev. 239, Issued: 01 -09-18 , Effective: 1-22-18, Implementation: 1-22-18)  Federally Qualified Health Centers (FQHCs) were established in 1990 by section 4161 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 and were effective beginning on October 1, 1991.  As with RHCs, they are also faci lities that are primarily engaged in providing services that are typically furnished in an outpatient clinic.  FQHCs were paid an AIR for primary health services and qualified preventive health services until October 1, 2014, when they began to transition to the FQHC prospective payment system (PPS).  Beginning on January 1, 2016, all FQHC are paid under the provisions of the FQHC PPS, as required by Section 10501(i)(3)(B) of the Affordable Care Act. FQHC services are defined as:    Physician services;    Services and supplies furnished incident to a physicians services;   NP, PA, certified nurse midwife (CNM), clinical psychologist (CP), and clinical social worker (CSW) services;    Services and supplies furnished incident to an NP, PA, CNM, or CP services; and   Outpatient diabetes self -management training (DSMT) and medical nutrition therapy (MNT) for beneficiaries with diabetes or renal disease.  The statutory requirements that FQHCs must meet to qualify for the Medicare benefit are in section 1861(aa)(4) of the Act.  No Part B deductible is applied to expenses for services that are payable under the FQHC benefit.  An entity that qualifies as an FQHC is assigned a CCN in the range 1800-1989 and 1000-1199. FQHC services also include certain preventive primary health services.  The law defines Medicare- covered preventive services provided by an FQHC as the preventive primary health services that an FQHC is required to provide under section 330 of the Public Health Service (PHS) Act.  Medicare may not cover some of the preventive services that FQHCs provide, such as dental services, which are specifically excluded under Medicare law.  There are 3 types of organizations that are eligible to enroll in Medicare as FQHCs:    Health Center Program Grantees: Organizations receiving grants under section 330 of the PHS Act, including Community Health Centers, Migrant Health Centers, Health Care for the Homeless Health Centers, and Public Housing Primary Care Centers;    Health Center Program Look -Alikes: Organizations  that hav e been identified by HRSA as meeting the definition of Health Center under section 330 of the PHS Act, but not receiving grant funding under section 330; and    Outpatient health programs/facilities operated by a tribe or tribal organization (under the In dian Self -Determination Act) or by an urban Indian organization (under Title V of the Indian Health Care Improvement Act).   NOTE:   Information in this chapter applies to FQHCs that are Health Center Program Grantees and Health Center Program Look- Alikes.  It does not necessarily apply to tribal or urban Indian FQHCs or grandfathered tribal FQHCs. An FQHC must:    Provide comprehensive  services and have an ongoing quality assurance program;    Meet other health and safety requirements;    Not be concurrently approved as an RHC; and    Meet all requirements contained in section 330 of the Public Health Service Act, including:   o Serve a designat ed Medically -Underserved Area (MUA) or Medically -Underserved Population (MUP);   o Offer a sliding fee scale to persons with incomes below 200 percent of the federal poverty level; and   o Be governed by a board of directors, of whom a majority of the members receive their care at the FQHC.  Additional information on these and other section 330 requirements can be found at http://bphc.hrsa.gov/ . Per 42 CFR 413.65(n) , only FQHCs that were operating as provider-based clinics prior to 1995 and either a) received funds under section 330 of the PHS Act or b) were determined by CMS to meet the criteria to be a look -alike clinic, are eligible to be certified as provider -based FQHCs.  Clinics that do not already have provider- based status as an FQHC are no longer permitted to receive the designation.  For information on claims processing, see to Pub. 100- 04, Medicare Claims Processing Manual, chapter 9, http://www.cms.gov/Regulations -and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf , and P ub. 100-07, State Operations Manual chapter 2, sections 2825 and 2826, http://www.cms.gov/Regulations -an d-Guidance/Guidance/Manuals/downloads/som107c02.pdf .  20 - RHC and FQHC Location Requirements  (Rev. 239, Issued: 01 -09-18 , Effective: 1-22-18, Implementation: 1-22-18)  To be eligible for certification as an RHC, a clinic must be located in 1) a non -urbanized area, as determined by the U.S. Census Bureau, and 2) an area designated or certified within the previous 4 years by the Secretary, HHS, in any one of the four types of shortage area designations that are accepted for RHC certification as listed in section 20.2. A clinic applying to become a Medicare- certified RHC must meet both the rural and underserved location requirements.  Mobile clinics must have a fixed schedule that specifies the date and location for services, and each location must meet the location requirements. Existing RHCs are not current ly required to continue to meet the location requirements.  RHCs that plan to relocate or expand should contact their Regional Office (RO) to determine their location requirements.  FQHCs may be located in rural or urban areas.  FQHCs that are Health Center Program Grantees or Look -Alikes must be located in or serve people from a HRSA-designated MUA or MUP.   20.1 - Non -Urbanized Area Requirement for RHCs  (Rev. 220, Issued: 01-15-16, Effective: 02-01-16, Implementation: 02-01-16)   The U.S. Census Bureau dete rmines if an area is an urbanized area (UA).  Any area that is not in a UA is considered a non-urbanized area.  A clinic located in an area that is not a UA would meet the RHC requirement for being in a non-urbanized area.  Information on whether an area is in an urbanized area can be found at http://factfinder.census.gov; or http://www.raconline.org ; or by contacting the appropriate CMS RO at http://www.cms.gov/RegionalOffices/ .  20.2 - Designated Shortage Area Requirement for RHCs  (Rev. 220, Issued: 01-15-16, Effective: 02-01-16, Implementation: 02-01-16)   The HRSA designates areas as MUAs/MUPs and/or Health Professional  Shortage Areas (HPSAs).  To be eligible for RHC certification, a clinic must be located in an area that has one of the following types of shortage area designations:   Geographic Primary Care HPSA;    Population- group Primary Care HPSA;    MUA (this does not include the population group MUP designation); or   Governor- Designated and Secretary -Certified Shortage Area (this does not include a Governors Medically Underserved Population designation).  No other type of shortage area designation is accepted for purposes of RHC certification.  The designation cannot be more than 4 years old in order to meet the requirement of being in a currently designated area.  For RHC purposes, the age of the designation is calculated as the last day of the year 4 years from the d ate of the original designation, or the date the area was last designated.  For example, a clinic that is located in an area that was most recently designated or updated on June 1, 2010, would be considered as meeting this location requirement through December 31, 2014.  Areas that are listed as proposed for withdrawal are considered designated.  The designation date is the date that the area was last updated, not when the area was proposed for withdrawal.  To determine the designation date of an area that is listed as proposed for withdrawal, contact HRSAs Shortage Designation Branch at sdb@hrsa.gov or call 1 -888-275-4772.  30 - RHC and FQHC Staffing Requirements  (Rev. 166, Issued: 01-31-13, Effective: 03-01-13, Implementation: 03 -01-13)   30.1 - RHC Staffing Requirements  (Rev. 239, Issued: 01 -09-18 , Effective: 1-22-18, Implementation: 1-22-18)  In addition to the location requirements, an RHC must:  Employ an NP or PA; and   Have an NP, PA, or CNM working at the clinic at least 50 percent of the time the clinic is operating as an RHC.  The employment may be full or part time, and is evidenced by a W- 2 form from the RHC.  If another entity such as a hospital has 100 percent ownership of the RHC, the W- 2 form can be from that entity as long as all the non -physician practitioners employed in the RHC receive their W -2 from this owner. The following are examples of situations that would NOT satisfy the employment requirement:   An NP or PA who is employed by a hospital that has an ownership interest in the RHC but is not physically present and working in the RHC;   A CNM who is employed by the RHC;    An Advanced Practice Registered Nurse who is not an NP or PA; or    An NP or PA who is working as a substitute in an arrangement  similar to a locum tenens physician.  An RHC practitioner is a physician, NP, PA, CNM, CP, or CSW.  At least one of these practitioners must be present in the RHC and available to furnish patient care at all times the RHC is in operation.  A clinic that is  open solely to address administrative matters or to provide shelter from inclement weather is not considered to be in operation during this period and is not subject to the staffing requirements.  An NP, PA, or CNM must be available to furnish patient care  at least 50 percent of the time that the RHC is open to provide patient care.  This requirement can be fulfilled through any combination of NPs, PAs, or CNMs as long as the total is at least 50 percent of the time the RHC is open to provide patient care.  Only the time that an NP, PA, or CNM spends in the RHC, or the time spent directly furnishing patient care in another location as an RHC practitioner, is counted towards the 50 percent time.  It does not include travel time to another location, or time sp ent not furnishing patient care when in another location outside the RHC (e.g. home, SNF, etc.).