Federally Qualified Health Center Demonstration Frequently Asked Questions
New FAQs (12/19/2011)
When conducting a chart abstraction to complete 3C, 3D, and 4A “Comment Needed” fields in the Readiness Assessment Survey every 6 months, should I only review charts from Medicare patients?
No. Charts should not be limited to the Medicare population. Responses provided in the “Comment Needed” fields should reflect the entire patient population.
I did not receive a care management payment on November 15th. What should I do?
The first care management payment was rescheduled from November 15th to mid/late December, 2011. Despite the delay, the first payment will include payment for the first three months of the Demonstration (November, December, and January).
My FQHC is currently in both the HRSA PCMHH Initiative and the CMS FQHC APCP Demonstration. When do I have to apply for recognition?
The HRSA PCMHH initiative asks participating Health Centers to submit for PCMH recognition within one year of submitting their Notice of Intent (NOI). The CMS FQHC APCP Demonstration requires FQHCs to achieve Level 3 NCQA PCMH Recognition by the end of the 3 year Demonstration. HRSA will work with FQHCs who are in both projects to make sure that there is no undue burden associated with fulfilling these expectations.
Can FQHCs participating in the Pioneer ACO Demonstration also participate in the CMS FQHC APCP Demonstration?
FQHCs participating in the Medicare FQHC APCP Demonstration may also participate in an ACO. ACOs receive money from shared savings, but not from Medicare through any kind of care management fee. Whereas FQHCs participating in the FQHC APCP Demonstration receive care management fees, but receive no shared savings. An ACO would have to show savings to receive reimbursement for services delivered, but the care management fee associated with the FQHC APCP demonstration is paid whether or not services are received by the beneficiary.
ACO payments, therefore, are distinctly different from FQHC APCP demonstration care management fees and cannot be considered in calculating ACO shared savings.
How are Medicare beneficiaries attributed to a particular FQHC?
Beneficiaries are attributed to an FQHC based on the “brick and mortar” site at which the beneficiary is seen for medical services. It is important that an FQHC submit claims to CMS based on the site at which the patient/Medicare beneficiary receives medical services, rather than the corporate office location.
Where can I find the slides, MP3 recording and transcript from the November 17th Participant Conference Call?
The slides and transcript from the November 17th Participant Conference Call can be found on the Center for Medicare Medicaid Innovation (CMMI) web site http://innovations.cms.gov/initiatives/FQHCs/index. Unfortunately, an MP3 recording is not available.
I have participated in the November 17th Participant Conference Call and/or reviewed the meeting materials. Now that the Demonstration has begun, what are my next steps in terms of participation?
The next step is to begin working toward achieving Level 3 PCMH recognition through NCQA. You should have received the FQHC Readiness Assessment Baseline Scores report that provides aggregate Readiness Assessment scores of all Demonstration Participants and information on FQHC Technical Assistance offerings. The next Readiness Assessment is due May 1, 2012. FQHC’s progress toward recognition will be evaluated at that time. We recommend that your practice begins working toward meeting the 2011 NCQA Standards now in preparation for the next Readiness Assessment.
Will FQHCs be receiving feedback on completed Readiness Assessments?
Yes, in December 2011 FQHCs have been sent a FQHC Readiness Assessment Baseline Scores report that provides aggregate Readiness Assessment scores of all Demonstration Participants. You will receive similar feedback after each six-month Readines Assessment update. Feedback will show the change from the baseline to the first six months and then subsequent months.
Will there be opportunities among participating FQHCs to share experiences or learn from the experiences of others such as a listserv or social networking opportunities?
Yes, CMS will provide opportunities for FQHCs in the Demonstration to collaborate and share best practices as a part of the technical assistance offerings. We will be sending out additional information on these collaboration opportunities.
At the time of beneficiary attribution, will FQHCs be receiving patient/beneficiary rosters?
No, CMS will be providing FQHCs aggregate information which is the number of beneficiaries that an FQHC will be paid for and the amount of payment. For operational reasons, CMS is not going to be able to give FQHCs beneficiary level data.
FAQS FROM APPLICATION PHASE
What is the FQHC Advanced Primary Care Practice Demonstration?
The initiative is designed to evaluate the impact of the advanced primary care practice (APCP) model, also known as the patient-centered medical home (PCMH), on improving health, improving quality of care, and lowering the cost of care provided to Medicare beneficiaries served by Federally Qualified Health Centers (FQHCs). Created by the Affordable Care Act, it will pay an estimated $42 million over three years to 500 FQHCs to coordinate care for almost 200,000 Medicare beneficiaries.
FQHCs provide essential primary care services to seniors, Medicare and Medicaid beneficiaries and others in underserved communities.
Participating FQHCs agree to pursue National Committee for Quality Assurance (NCQA) Level 3 PCMH (patient-centered medical home) recognition. APCPs/medical homes provide patients with coordinated health care delivery, develop strong physician-patient relationships, encourage communication, and incorporate electronic systems to improve health outcomes.
CMS will conduct an independent evaluation of the FQHC APCP Demonstration. The evaluation will study the process and challenges involved in transforming FQHCs into APCPs and assess the effects of the APCP model on access, quality and cost of care provided to Medicare and Medicaid beneficiaries served by FQHCs. In addition, the evaluation will assess whether the Demonstration was budget neutral and whether the goals of the Demonstration were met.
For more information see the CMS FQHC APCP Demonstration website.
How long will the Demonstration last?
The three-year Demonstration will start November 1, 2011 and end October 31, 2014.
Will additional FQHCs be added in Years Two and Three of the Demonstration? Will FQHCs be added to compensate for attrition?
No. FQHCs will not be added in Years Two and Three or to compensate for attrition. However, if additional funding is made available in the future, it may be possible to expand the Demonstration and select additional eligible FQHC practices to participate.
PARTICIPATING IN OTHER DEMONSTRATIONS
Can FQHCs participate in both the FQHC APCP Demonstration and the MAPCP Demonstration initiative?
FQHCs may not receive payments for providing the same services to a beneficiary from more than one CMS Demonstration simultaneously. In the case of the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration, FQHCs must choose between the two Demonstrations (FQHC APCP or MAPCP). FQHCs will not be able to switch Demonstrations later, and will not be reimbursed by both Demonstrations.
Is the FQHC APCP Demonstration the same as the HRSA initiative?
No. The FQHC APCP Demonstration is a 3-year initiative sponsored by CMS. Information on HRSA’s grant opportunity, “HRSA Patient-Centered Medical/Health Home Initiative” can be found at: http://bphc.hrsa.gov/policiesregulations/policies/pal201101.html
Can FQHCs participate in both the FQHC APCP and the HRSA Patient-Centered Medical/Health Home Initiative (PCMHHI)?
FQHC participation in HRSA Patient-Centered Medical/Health Home Initiative (PCMHHI) does not mean that the FQHC is necessarily participating in the CMS FQHC APCP Demonstration, nor does it preclude participation in the FQHC APCP Demonstration. FQHCs may participate in both the PCMHHI initiative and the FQHC APCP Demonstration.
CHANGES TO PARTICIPANT INFORMATION
Who should be contacted if a participating FQHC site moves or closes?
The FQHC should notify email@example.com as soon as possible in addition to notifying their billing contractor(s) and updating their information on the applicant portal: https://recognitionportal.ncqa.org/rponlineapp/login.aspx
Who should be contacted if the contact person at a participating FQHC changes?
Notify firstname.lastname@example.org as soon as possible.
What should we do if one of our participating sites changes to a specialty-only site for such services as dental, vision, podiatry?
Notify email@example.com as soon as possible.
EXPECTATIONS FOR SELECTED FQHCS
What are the Demonstration Terms and Conditions?
The Demonstration Terms and Conditions are as follows:
- The FQHC agrees to pursue Level 3 PCMH recognition from the National Committee for Quality Assurance (NCQA) by the end of the Demonstration.
- The FQHC agrees to remain in the Demonstration for the 3-year duration beginning November 1, 2011.
- The FQHC agrees to submit an application to participate in the Demonstration no later than 11:59pm on Friday, September 9, 2011, and an initial Patient Centered Medical Home (PCMH) readiness assessment as part of the application process by no later than 11:59pm (ET) on Friday, September 16, 2011.
- The FQHC agrees to submit an updated readiness assessment every 6 months for the duration of the Demonstration.
- The FQHC agrees to cooperate with the organization CMS engages to evaluate the Demonstration. This may include providing additional information or data.
- The FQHC agrees to comply with all monitoring requirements. This includes updating the readiness assessment every 6 months throughout the Demonstration.
- The FQHC must attest that it is not currently under a corrective action plan from HRSA for serious safety or financial issues.
- The FQHC acknowledges that CMS can terminate participation in the Demonstration for failure to progress toward PCMH recognition based on periodic readiness assessment scores.
- The FQHC acknowledges that CMS can terminate participation in the Demonstration by any FQHC that has committed Medicare fraud.
- By applying to participate the FQHC agrees to participate in learning cooperatives and other technical assistance that is offered by CMS and HRSA.
- The FQHC acknowledges that failure to comply with all terms and conditions may result in disqualification from the Demonstration.
- These terms and conditions are subject to change in the interest of improving results under the Demonstration. Such changes would require the consent/approval of both parties and at least 30 days advance notice to facilitate their implementation.
What are participating FQHCs expected to do in the Demonstration?
Participating FQHCs agree to pursue Level 3 PCMH (patient-centered medical home) recognition, as determined by meeting NCQA 2011 standards, by the end of the Demonstration (October 2014). This means that participating FQHCs will make whatever practice changes and/or improvements necessary to document, to the satisfaction of the NCQA 2011 PCMH standards, that the FQHC is capable of providing comprehensive, coordinated, patient-centered primary care as would be the case in any patient-centered medical home. CMS expects participating FQHCs to channel the care management fees received from the Demonstration into the transformation of the practice to offset any additional costs associated with becoming a recognized PCMH medical home. CMS further expects that participating FQHCs will actively participate in the technical assistance offered to assist in the transformation, comply with the requirement to update the PCMH readiness assessment every 6 months to determine progress, and to cooperate with the CMS evaluation contractor to provide additional data and information as will be needed to measure the results of the Demonstration.
CARE MANAGEMENT FEE
What is the Care Management Fee?
The Care Management Fee is a fee paid to each participating FQHC prospectively, on a quarterly basis for each eligible Medicare beneficiary that is attributed by CMS to the FQHC. CMS uses administrative claims data to identify Medicare beneficiaries that have received medical services from an FQHC within the previous 12 month period (look-back period). A fee of $18 per beneficiary per quarter ($6 per beneficiary per month) will be paid electronically to the FQHC directly without the need to submit a claim. The care management fee is in addition to and exclusive of the usual all inclusive payment that is paid to FQHCs for covered services through claims submission. However, care management fees should not be included in annual cost reporting or be used to calculate all inclusive payment amounts.
How are Medicare beneficiaries “attributed” for payment purposes?
CMS uses administrative claims data to identify beneficiaries that have received medical services from a participating FQHC. Claims data are examined to identify Medicare beneficiaries that are covered by Medicare Part A and fee-for-service Part B, are not participating in a Medicare Advantage (MA) plan, are not currently in hospice care, and are not being treated for end stage renal disease (ESRD). Beneficiaries are attributed to the FQHC from which they have received the plurality of their care within the previous 12 month (look-back) period. In cases where a beneficiary has visited more than one FQHC equally, the beneficiary will be assigned to the FQHC associated with the most recent visit.
Beneficiary eligibility may change over the course of the Demonstration for many reasons (death, change in coverage, etc.). Therefore, beneficiary eligibility will be verified each quarter prior to payment.
Participating FQHCs will not be permitted to challenge attribution.
Will quarterly fee payments be adjusted for any disenrollment that occurs during the quarter?
No. Adjustments will only be made quarterly for any disenrollment identified during the quarterly eligibility review. Fee payments will not be adjusted retroactively.
Will there be any retroactive adjustments made for patients who die, go to managed care, move out of state?
No. No retroactive adjustments will be made to previously paid care management fees. Beneficiaries who die, move out of state or go to Medicare Advantage (managed care) will “fall off” future attribution lists as they are deleted from the Medicare FFS rolls associated with the FQHC.
Can a disqualified beneficiary whose status changes later in the Demonstration (i.e. leaves Medicare Advantage for fee for service) be re-attributed?
Yes. If a beneficiary appears eligible during a quarterly eligibility review they can be attributed to the FQHC according to the attribution rules.
What will happen if an FQHC’s beneficiary population falls below 200?
If a participating FQHC’s beneficiary population falls below 200, the FQHC will remain eligible to participate in the Demonstration. It is understood that patient panels fluctuate from quarter to quarter.
What if an FQHC feels that some patients have been erroneously left off the Attribution/Payment Lists/Rosters?
Care management fees are not meant to be an actual per-beneficiary-per-month payment, but rather an approximate payment to compensate FQHCs for the additional activities and/or services provided to all Medicare FFS beneficiaries under the Demonstration. As a condition of participation, FQHCs are not permitted to challenge the beneficiary attribution.
Who should FQHCs contact if they do not receive an EFT payment by the expected date or if there are other payment issues?
FQHCs should contact their CMS payment contractor for this Demonstration and also contact firstname.lastname@example.org.
What are the monitoring / evaluation activities for participating FQHCs?
Participating FQHCs agree to pursue National Committee for Quality Assurance (NCQA) Level 3 PCMH (patient-centered medical home) recognition. In addition, participating FQHCs agree to cooperate with the organization CMS engages to evaluate the Demonstration. This may include providing additional information or data. The FQHCs agree to comply with all monitoring requirements. This includes completing a Readiness Assessment Update every 6 months throughout the Demonstration and being subject to a Random Audit of Readiness Assessment responses. Finally, the FQHCs agree to participate in learning collaboratives and other technical assistance offered by CMS and HRSA.
How will CMS monitor FQHC progress in meeting Demonstration goals?
CMS will monitor each participant’s transformation progress by comparing Readiness Assessment scores at baseline with Readiness Assessment scores updated every 6 months.
What will happen if FQHCs are not progressing?
Each participating FQHC has agreed to pursue Level 3 PCMH recognition. If noticeable progress is not being made, CMS will analyze the circumstances and recommend the FQHC use additional technical assistance resources to overcome barriers. In addition, CMS may terminate the FQHC for failure to comply with all Terms and Conditions.
At the end of the Demonstration, will there be a Report to Congress or some other publication of findings? Will the results from my FQHC be made public?
The annual and final evaluation reports will be made available. No information on the performance of individual FQHCs will be reported publicly.
How will CMS determine whether the Demonstration is a success?
CMS will be conducting an independent evaluation of the FQHC APCP Demonstration. The evaluation will study the process and challenges involved in transforming FQHCs into APCPs and assess the effects of the APCP model on access, quality and cost of care provided to Medicare and Medicaid beneficiaries served by FQHCs. In addition, the evaluation will assess whether the Demonstration was budget neutral and whether the goals of the Demonstration were met.
What if, at some point during the Demonstration, an FQHC comes under a HRSA corrective action?
CMS will monitor sites under HRSA corrective action throughout the Demonstration and reserves the right to terminate an FQHC from the Demonstration for failure to meet this and other Demonstration requirements.
Will there be any penalty, financial or otherwise, if an FQHC must withdraw from the Demonstration?
Will there be a take-back of payments for FQHCs that do not achieve NCQA Level 3 recognition by the end of the Demonstration?
TECHNICAL ASSISTANCE AND OTHER SUPPORT
Is technical assistance available for participating FQHCs?
CMS and HRSA will make technical assistance available to participating FQHCs to support their transformation and achieve NCQA recognition as a PCMH at no cost to participating FQHCs.
HRSA has developed a series of technical assistance and training resources that highlight successful strategies for obtaining and maintaining PCMH recognition status. These training opportunities include educational and training sessions, and Webinars focused on understanding NCQA standards, as well as mock surveys to gain experience with the NCQA PCMH recognition process and documentation requirements. CMS is developing transformational learning systems to assist participating FQHCs to successfully transform their practice into a recognized patient-centered medical home.
Is other technical assistance for helping FQHCs through the transformation process available?
The Health Center Controlled networks (HCCNs) and Primary Care associations (PCAs) will be enlisted as a sustainable improvement support for infrastructure and the Health Resources and Services Administration (HRSA) will build on their core relationship with the FQHCs in collaboration with CMS to support the FQHCs to transform primary care.
Where can information be found about the technical assistance in which FQHCs will be required to participate?
Information will be provided to FQHCs at a later date.
Other than the planned technical assistance, will CMS or NCQA provide a contact we could speak with regarding specific questions we may have as our practice evolves into a fully capable APCP?
Information will be provided to FQHCs at a later date.
Who should be contacted for general questions about the Demonstration?