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The purpose
of this Program Assistance Letter (PAL)
is to provide information regarding
fiscal year (FY) 2001 appropriations
for programs funded by the Bureau of
Primary Health Care (BPHC), as well
as other legislation that is relevant
to BPHC programs, including the new
Prospective Payment System (PPS) for
Federally Qualified Health Centers (FQHCs)
and Rural Health Clinics (RHCs); the
Children’s Health Act of 2000;
the Breast and Cervical Cancer Prevention
and Treatment Act of 2000; and new regulations
on Medical Records Privacy issued under
the Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
On December
21, 2000, the President signed the “Consolidated
Appropriations Act, 2001" (Public
Law (P.L.) 106-554), which includes
funding for FY 2001 for programs funded
by the Department of Health and Human
Services (HHS). The major provisions
affecting BPHC programs include:
Appropriations
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$1,168,700,000 for the health center
cluster including the Community and
Migrant Health Centers, the Health
Care for the Homeless Program, the
Public Housing Primary Care Program,
and the Healthy Schools, Healthy Communities
Program. This is a $150 million increase
over the FY 2000 funding level (a
future PAL will detail a spending
plan for the $150 million increase
for health centers). Of this amount,
$6,250,000 is to be spent for Native
Hawaiian health programs.
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$41,523,000 for the National Health
Service Corps (NHSC) Field Placements.
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$87,924,000 for NHSC Recruitment (minus
$4,000,000 for State Offices of Rural
Health).
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$18,016,000 for Hansen’s Disease
Services, of which $900,000 is to
be allocated to the Diabetes Lower
Extremity Amputation Prevention Program
at the University of Alabama.
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$6,000,000 for Black Lung Clinics.
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$140,000,000 for health care access
for the uninsured (i.e., the Community
Access Program) - of which, $125,000,000
is for grants to public, private,
and non-profit health entities to
develop and expand integrated systems
of care and address service gaps within
these integrated systems with a focus
on primary care, mental health services,
and substance abuse services. The
remaining $15,000,000 is to continue
to help States identify the characteristics
of the uninsured within the State
and approaches for providing all uninsured
with health coverage through an expanded
State, Federal, and private partnership.
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$44,400,000 for Ryan White Title III
planning grants, early intervention
service (EIS) grants to minority community-based
health care and service providers
with a history of service provision
to communities of color. The funding
increase is to be directed primarily
towards providing early intervention
service grants to organizations that
received Title III planning grants
in the previous fiscal year and enhancing
the service capacity of existing minority
EIS providers.
The Consolidated Appropriations Act,
P. L. 106-554, incorporates the text
of Medicare, Medicaid and State Children’s
Health Insurance Program (SCHIP) Benefits
Improvement Act of 2000 (BIPA, H.R.
5661) that includes section 702: New
PPS for FQHCs and RHCs. This section
repeals the Balanced Budget Act (BBA)
of 1997 that would have phased-out the
reasonable costbased reimbursement system
found in section 1902(a)(13)(C) of the
Social Security Act. In its place, the
new law establishes a prospective payment
methodology to guarantee health centers
a minimum per visit payment for services
provided to Medicaid beneficiaries.
For Medicaid services provided between
January 1, 2001, and September 30, 2001,
States are required to reimburse FQHCs
and RHCs at 100 percent of the average
costs of providing FQHC and RHC services
to Medicaid beneficiaries for the 2
previous FYs (1999 and 2000) with adjustments
made for changes in the scope of services
provided by the FQHC and RHC. Payment
amounts are calculated on a per visit
basis. For FY 2002 and years thereafter,
FQHCs and RHCs will be reimbursed based
on the previous year’s payments,
increased by that year’s Medicare
Economic Index for primary care and
adjusted for changes in a FQHC’s
and RHC’s scope of services.
Those FQHCs and RHCs that are established
on or after January 1, 2001, in their
first year will be reimbursed in an
amount equal to 100 percent of costs
for providing Medicaid services. Costs
are determined based on rates established
by the prospective payment methodology
for other FQHCs and RHCs located in
the same or adjacent area with a similar
caseload. In the absence of such a center
or clinic, a newly established FQHC
or RHC clinic will be reimbursed in
accordance with the prospective payment
methodology or on other tests of reasonableness
as the Secretary of Health and Human
Services may specify.
For those FQHCs and RHCs working within
managed care arrangements, BIPA maintains
the “wrap-around” payments
established by the BBA. The FQHCs and
RHCs will receive supplemental payments
from the State for the difference between
the amount they would have received
under the prospective payment methodology
and the amount received under contract
with the managed care organization.
Supplemental payments must be made pursuant
to a payment schedule agreed to by the
State and the FQHC or RHC and in no
case may occur less frequently than
every 4 months.
A State may use an alternative payment
methodology to reimburse FQHCs and RHCs
for services rendered to Medicaid beneficiaries
as long as such an alternative methodology
(1) reimburses FQHCs and RHCs no less
than the amount that they would be reimbursed
using the prospective payment methodology
and (2) the health center agrees to
that ethodology.
The law requires the Comptroller General
to initiate a study on how to rebase
or refine cost reimbursement methodologies
for services to FQHCs and RHCs within
the fourth year after enactment.
The “Children’s Health
Act of 2000" (P. L. 106-310), enacted
on October 17, 2000, expands and coordinates
research, prevention, and treatment
activities for conditions having a significant
impact on children, including autism,
diabetes, asthma, hearing loss, epilepsy,
traumatic brain injury, infant mortality,
lead poisoning, and oral health. It
also authorizes the Healthy Start program
for the first time. Particular new items
of interest that are community focused
include:
Asthma
The legislation adds a new section 399L
authorizing the Secretary to award grants
to eligible entities (public or nonprofit
entities or a consortium) to provide
access to quality medical care for children
who live in areas that have a high prevalence
of asthma and who lack access to medical
care. The program is to provide on-site
education and training, decrease preventable
trips to emergency rooms, and provide
services that ameliorate conditions
that induce asthma. In short, the grants
are to provide comprehensive asthma
services to children.
Oral Health
The legislation also authorizes a new
program to fund innovative oral health
activities that improve the oral health
of children under 6 years of age who
are eligible for services provided under
Medicaid, SCHIP, or other Federal health
programs. These activities should increase
the utilization of dental services by
eligible children and decrease the incidence
of early childhood and baby bottle tooth
decay. The Children’s Health Act
authorizes funding for 5 years at $10
million dollars each year through grants
to dental schools, other dental training
programs, and community dental programs
in areas where the incidence of early
childhood caries is the highest.
Adoption Awareness Training
A new grant program is established to
train designated staff of “eligible
health centers” in providing adoption
information and referrals to pregnant
women on an equal basis with all other
courses of action. The grants would
be made to national, regional, or local
adoption organizations. Grants will
be awarded on the condition that the
recipient make a reasonable effort to
ensure that training is provided to
staff of voluntary family planning projects,
section 330 health centers, and eligible
health centers receiving grants under
this Act.
Approximately $9.9 million dollars was
appropriated to implement this program.
There are also provisions for a report
to Congress evaluating the extent to
which adoption information and referral,
upon request, are provided by eligible
health centers and a report, after training
is initiated, to determine the effectiveness
of the training upon the provision of
adoption and referral information by
health center staff.
Homeless Individuals
The Children’s Health Act also
includes the Substance Abuse and Mental
Health Services Administration reauthorization.
Of particular interest is the Grants
for the Benefit of Homeless Individuals
Program, which provides grants to develop
and expand mental health and substance
abuse treatment services to homeless
individuals. Preference is maintained
for organizations that provide integrated
primary health care, substance abuse
and mental health services to homeless
individuals, programs that demonstrate
effectiveness in serving homeless individuals,
and programs that have experience in
providing housing for individuals who
are homeless. Ten million dollars was
appropriated for this program.
Emergency Mental Health Centers
Section 3209 of the new law authorizes
$25 million for the Secretary to make
grants to States, political subdivisions
of States, Indian tribes and tribal
organizations to support the designation
of health centers as Emergency Mental
Health Centers, to serve as central
receiving points in the communities
for individuals who may be in need of
emergency mental health services.
On Tuesday, October 24, 2000, the
President signed the "Breast and
Cervical Cancer Protection and Treatment
Act of 2000" (BCCPTA). It amends
the Medicaid legislation to create a
new State option to provide full Medicaid
benefits to uninsured women under age
65 who have been screened under the
Centers for Disease Control and Prevention’s
Breast and Cervical Cancer Early Detection
Program (Title XV of the Public Health
Service Act) and identified as needing
treatment for breast or cervical cancer.
Although many health centers are not
official participants in the Title XV
screening program, centers play a critical
role in screening uninsured or underinsured
women. Since women’s eligibility
for Medicaid coverage under the BCCPTA
depends on whether they receive their
cancer screenings from providers that
are part of the Title XV screening program,
it is critical that health centers be
recognized as members of their State’s
Title XV program. On January 4, 2001,
in a letter to State Health Officials,
the Health Care Financing Administration
(HCFA) announced that for purposes of
the BCCPTA, States may consider women
to have been "screened under the
program," and therefore be eligible
for treatment benefits, if they are
screened at a family planning or community
health center – even where the
center is not officially part of its
State’s Title XV screening program.
This new option has the potential to
offer significant benefits to women
who are screened by health centers.
We urge those grantees that offer breast
and cervical cancer screenings to work
with your State health agency, Primary
Care Association, and other health centers
to ensure that you are formally acknowledged
as screening sites under the Title XV
program so that your clients are eligible
for treatment coverage under the Medicaid
program if needed. For more detailed
information, please see the full text
of the January 4, 2001, HCFA letter.
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This law seeks to guarantee that the
U.S. Government provide fair compensation
to the thousands of individuals adversely
affected by the mining of uranium
and from fallout during the testing
of nuclear weapons in the early post-war
years. This amended Radiation Exposure
Compensation Act (RECA) law requires
the Federal Government, administered
through the Justice Department, to
compensate those individuals who worked
in underground uranium mines, or to
above-ground workers now affected
by the same health conditions, who
were harmed in Colorado, New Mexico,
Arizona, Wyoming, Utah, Idaho, Oregon,
Texas, Washington, South Dakota and
North Dakota.
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The RECA Amendments authorize the
Secretary of Health and Human Services
to make grants, in the amount of $20
million annually, to cancer centers,
Veteran’s Administration medical
centers, community health centers,
and State health departments to carry
out screening programs for eligible
individuals for the early warning
signs of cancer, provide medical referrals,
educate individuals on radiogenic
cancers and prevention, and facilitate
documentation of RECA claims. In particular,
the law’s section 417C, Grants
for Education, Prevention, and Early
Detection of Radiogenic Cancers and
Diseases, provides that the Secretary,
acting through the Administrator of
the Health Resources and Services
Administration in consultation with
the Director of the National Institutes
of Health and the Director of the
Indian Health Service, may make competitive
grants to any entity (including FQHCs,
community health centers) for the
purpose of carrying out programs to:
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screen individuals described under
the RECA for cancer as a preventive
health measure;
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provide appropriate referrals for
medical treatment of eligible individuals,
and for appropriate follow-up services;
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develop and disseminate public information
and education programs for the detection,
prevention, and treatment of radiogenic
cancers and diseases; and
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facilitate putative applicants in
the documentation of claims.
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Community health centers in the 11
affected States, and those community
health centers in
other parts of the United States,
which are treating or are expecting
to treat eligible
individuals who worked for at least
40 months in above-ground or underground,
open pit
uranium mines, uranium mills, or who
transported uranium ore within the
11 States (and
who may have since moved) would be
eligible for this grant money for
detection,
prevention, and education.
This new law includes the “Lupus
Research and Care Amendments of 2000”
(Title V) which amends the Public Health
Service Act to provide for research
and delivery of services with respect
to the auto-immune disease.
Subtitle B of Title V mandates grants
for the establishment, operation, and
coordination of effective and cost-efficient
systems for the delivery of essential
services to individuals with lupus and
their families. The program will provide
grants for diagnosing and managing lupus
to eligible entities including community
health centers, migrant health centers,
and homeless health centers.
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Subtitle B addresses on-going primary
care and treatment needs of poor and
uninsured individuals with this debilitating
disease. Grants for providing out-patient
care and support services may include
the following project activities:
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delivering or enhancing outpatient,
ambulatory, and home-based health
and support services, including
case management and comprehensive
treatment services, for individuals
with lupus; and delivering or
enhancing support for their families;
and
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improving the quality, availability,
and organization of health care
and support services (including
transportation services, attendant
care, homemaker services, day
or respite care, and providing
counseling on financial assistance
and insurance) for individuals
with lupus and support services
for their families.
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Subtitle B also expressly requires
this grant program to be carried out
by integrating it with other grant
programs, including the section 330
program.
The HIPAA required Congress to enact
national medical records privacy standards
by August 21, 1999. Congress failed
to meet this deadline, and the task
of creating standards shifted to the
HHS, as mandated under HIPAA. Final
regulations were published in the Federal
Register on December 28, 2000, and compliance
is required by February 26, 2003. (Small
health plans, or those with annual receipts
of $5 million or less, have 3 years
to comply.) Health centers are considered
“health care providers”
under the regulations and thus must
comply with HIPAA privacy rules within
the requisite timeframe.
The new regulations provide comprehensive
protection for the privacy of personal
medical records and information created
and maintained by health care providers,
insurers, and plans. Although various
State privacy laws currently exist,
until now, there has been no uniform
national standard for the protection
of medical information. Specifically,
the new regulations:
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apply to all types of records, including
electronic records, paper records,
and oral communications;
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require that providers obtain patients’
advance written consent for both routine
and nonroutine use and disclosure
of health records;
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establish civil money penalties and
Federal criminal penalties for violations
of the privacy standards, including
imprisonment for knowing and intentional
misuse of protected medical information;
and
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give patients new rights to access
their medical records and to know
who else has accessed them.
In light of these new regulations, health
centers need to evaluate the manner in
which they handle patient information,
educate themselves regarding the HIPAA
regulations, and prepare their staff and
information systems for an adjustment
to the new standards. Please see the HRSA
Web site for further medical records privacy
and HIPAA information, updates, and Internet
links.
If you have any questions regarding this
information, please contact William Melling
within the Office of Program and Policy
Development at (301) 594-4063 or e-mail
at wmelling@hrsa.gov.
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