FQHC General Information

10.2 - FQHC General Information (Rev. 12832; Issued: 09-12-24; Effective:01-01-24; Implementation:10-14-24) 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 facilities 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 FQHCs 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 physician’s services; • NP, PA, certified nurse midwife (CNM), clinical psychologist (CP), clinical social worker (CSW), marriage and family therapist (MFT), and mental health counselor (MHC) services; • Services and supplies furnished incident to an NP, PA, CNM, CP, MFT or MHC 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 have 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 Indian 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 designated 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 Pub. 100-07, State Operations Manual chapter 2, sections 2825 and 2826, http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/downloads/som107c02.pdf.