SUMMARY OF COMMENTS FROM NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS (NACHC)

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1 May 29, 2015 Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS 3310 P P.O. Box 8013 Baltimore, MD Main Office 7501 Wisconsin Ave. Suite 1100W Bethesda, MD Tel Fax Division of Federal, State and Public Affairs 1400 Eye Street, NW Suite 910 Washington, DC Tel FAX Submitted via RE: CMS 3310 P NPRM on Medicare and Medicaid Programs; Electronic Health Record Incentive Program Stage 3 The National Association of Community Health Centers, Inc. ( NACHC ) appreciates the opportunity to provide comments in response to the proposed rule regarding Medicare and Medicaid Electronic Health Records (EHR) Incentives Stage 3 Meaningful Use Criteria, which was published by the Centers for Medicare and Medicaid Services ( CMS ) on March 30, NACHC is the national membership organization for federally qualified health centers (hereinafter referred to as FQHCs or health centers ). Health centers play a critical role in the health care system, serving as the health home to over 23 million people. With over 9,300 sites, they provide affordable, high quality, comprehensive primary care to medically underserved individuals, regardless of their insurance status or ability to pay for services. For additional information on health centers, please see the attachment. In 2013, approximately 88 percent of health centers had fully operational EHR systems in all of their sites, and another 8 percent were operational in some of their sites. 1 Health centers operate on very slim margins (typically less than 1 percent), and often cite the high cost of EHR systems as a barrier to adopting and implementing them. As such, they must rely heavily on outside funding to support these activities. Recent increases in health centers implementation of EHRs is due in large part to the Medicaid EHR incentives and meaningful use standards. SUMMARY OF COMMENTS FROM NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS (NACHC) NACHC is focusing its comments primarily on issues that are of particular importance to FQHCs and their eligible professionals (EPs) in their efforts to ensure access to high quality, cost effective, patientcentered care for medically vulnerable patients and populations. We have divided our comments into two categories: general recommendations, and comments related to specific reporting objectives or measures. Below please find a summary of these comments, followed by a detailed discussion of each HRSA Uniform Data System (UDS) Report

2 Summary of General Recommendations 1. Shorten the 2018 EHR reporting period to 90 days. 2. For eligible providers who work at more than one location but meet MU at a single location where more than 50 percent of their encounters occur, reduce reporting burden by requiring them to report only on the one location. 3. Establish a national tracking mechanism by which Medicaid EPs who are affiliated with FQHCs can be distinguished from other Medicaid providers, and collect this data at the national level. 4. Require and incentivize the standardized collection and use of data regarding social determinants of health (including sexual orientation and gender identity.) Mandate that these data elements be part of the base EHR certification definition and the Common Clinical Data Set. Summary of Comments on Specific Objectives and Measures: 1. Protect Patient Health Information: Clarify that Security Risk Assessments (SRAs) are to be conducted by employers/ organizations, rather than eligible providers. 2. Electronic Prescribing (erx): Require that formulary checks be done automatically, and indicate drugs that ARE covered when the selected drug is not. 3. Computerized Provider Order Entry (CPOE): Clarify the appropriate use of scribes to do Computerized Provider Order Entry (CPOE), including permitting Veteran MAs to continue doing the same tasks they did prior to the introduction of CPOE requirements 4. Patient Electronic Access to Health Information (AHI): Ensure that measures are attainable through CEHRT, and do not require the purchase of add on products. Encourage the aggregation of individual patient s data from multiple EPs into a single site; clarify which accounts are included in the numerator for this measure. Extend turnaround time to 72 hours. 5. Patient Engagement: Recognize the financial and linguistic challenges faced by health center patients, and reduce the degree to which EPs are held accountable for patient behavior that is beyond their control, by lowering the patient engagement thresholds from VDT from 25 percent to 10 percent, secure messaging from 35 percent to 10 percent, and patient generating data from 15 percent to 5 percent. Permit any EP who contributes to a secure patient message (not just the initiating EP) to count that patient in their Secure Messaging measure. Reconsider the measure on incorporating patient generated health data into the EHR. 6. Care Transitions and Referrals:

3 Continue the development of the Nationwide Health Information Network, and the alignment of efforts to advance this goal. Ensure that all functionality required for meaningful use is be part of the core EHRT and not dependent on the purchase of third party add on software packages, interfaces, etc. 7. Public Health and Clinical Data Registry Reporting: Clarify that public health measures are to be met by the site, not the EP. Finalize the use of the term active engagement in these measures. Finalize proposals to create a centralized repository of national, state, and local PHA and CDR readiness, and to develop a national infrastructure to support more standardized reporting of measures such as immunizations. DETAILED COMMENTS ON GENERAL REPORTING REQUIREMENTS 1. Shorten the EHR reporting period for 2018 to 90 days. Proposal: The NPRM proposes to require all providers to use EHR technology certified to the 2015 Edition for a full calendar year for the EHR reporting period in Comment: As evidenced by the issues related to EHR technology certified to the 2014 Edition, including significant delays and lackluster initial Stage 2 attestation numbers, the development, installation, testing, training, and deployment of new certified technology takes a significant amount of time to get right. Because of stringent timelines imposed by the original Stage 2 rule and vendors who could not get their certified products out the door fast enough, many 2014 certified EHR products were delayed and subsequently released without undergoing proper quality assurance and control testing. As a result, many health centers who upgraded on time had unstable software, which adversely impacted the operations of their practice and ultimately jeopardized the safety of their patients. It is for this reason that NACHC strongly recommends CMS establish a 90 day EHR reporting period in This will allow sufficient time for the vendors to develop the new technology needed to support the Stage 3 rule while also allowing practices sufficient time to upgrade their EHRs, train their staff, and roll out the new software across all of their sites. This change would also be consistent with CMS recent decision to maintain the 90 day EHR reporting period for a provider s first payment year in the Medicaid EHR incentive program. 2. For eligible providers who work at more than one location but meet MU at a single location where more than 50 percent of their encounters occur, reduce reporting burden by requiring them to report only on the one location. Proposal: Similar to the Stage 2 Final Rule, this NPRM requires that EPs must have 50 percent or more of their outpatient encounters during the EHR reporting period at a practice(s)/location(s) equipped with CEHRT. In addition, EPs who work at more than one location must compile and submit data from each of these sites, even if one site accounts for more than 50 percent of their encounters and they have met MU at that site.

4 Comments: If an EP has met MU at a location where more than 50 percent of his/her encounters occur, then the EP has demonstrated that he/she knows how to perform as a meaningful user. Requiring the EP to compile data from other sites is burdensome and has no impact on whether the EP meets the MU standard. Recommendation: When an EP works at more than one site, and can demonstrate that they have met MU at a single site that accounts for over 50 percent of their encounters, do not require the EP to report data on other practice locations. 3. Establish a national tracking mechanism by which Medicaid EPs who are affiliated with FQHCs can be distinguished from other Medicaid providers, and collect this data at the national level. Comments: Community Health Centers are the largest network of providers in the country yet their participation in the Medicaid EHR incentive program cannot be reliably and accurately measured on a national scale. This is due to the program s structure (e.g. EP versus organization level) and the fact that EP data is currently tracked by State Medicaid agencies, but does not flow up to the national level. Recommendation: Develop a national tracking mechanism by which Medicaid EPs who are affiliated with FQHCs can be distinguished from other Medicaid providers. States should report this information to CMS, HRSA, ONC, and NACHC on a recurring basis so progress can be measured and training and technical resources channeled accordingly. 4. Require and incentivize the standardized and structured collection and use of social determinants of health and sexual orientation and gender identity data. Mandate that these data elements be part of the base EHR certification definition and the Common Clinical Data Set. Comments: As HHS has outlined in Healthy People 2020 ( determinants health), health care is only one of five major categories of factors that determine an individual s health status and ability to benefit from appropriate health care services. The other four all of which fall outside the range of clinical care are: Economic Stability; Education; Social and Community Context; and Neighborhood and Built Environment. Due to the importance of these upstream factors in determining how a patient will respond to health care, as well as the non medical supports they may need in order to effectively improve outcomes, clinical data alone do not provide a complete picture of the context in which providers operate. This is particularly true for safety net providers, such as FQHCs, whose patients are generally at a significant disadvantage with regards to SDOHs compared to the general population. Because these Social Determinants of Health (SDOHs) contribute to patient complexity and severity in ways that are not adequately captured by clinical diagnoses, and because the SDOH contribute to the etiology and trajectory of disease outcomes (Institute of Medicine, 2014), safety net providers are disadvantaged when payment and public reporting are based on patient outcomes without regard to underlying, nonclinical risk factors. Current risk adjustment methodologies do not adequately capture these non clinical

5 risk factors, and research demonstrates that this can undervalue the providers who serve populations facing significant SDOH challenges (Hong et al, 2010; Chien et al, 2012). National initiatives are promoting the collection of standardized patient level non clinical risk factors through the EHR. Most notably, the Institute of Medicine recently published recommendations of social factors to be considered under Meaningful Use Stage 3 ( and these are reflected in and proposed in ONC s 2015 EHR certification criteria. Recommendation: Consistent with the IOM s recommendations, CMS should require and incentivize the standardized and structured collection and use of data on social, psychological, and behavioral factors (including sexual orientation and gender identity) that have been shown to impact health status, health outcomes, and population health. This will result in more extensive and consistent collection of this data in EHRs, which will be an important step towards addressing health disparities and improving health outcomes among vulnerable populations nationwide. CMS should also mandate that these social, psychological, and behavioral data elements (as outlined in the 2015 certification NPRM, and commented on by NACHC) be a required part of both the base EHR certification definition and the Common Clinical Data Set. SUPPORTING COMMENTS ON SPECIFIC OBJECTIVES AND MEASURES: 1. Protect Patient Health Information: Clarify that Security Risk Assessments (SRAs) should be conducted by employers/ organizations, rather than eligible providers. Proposed Measure: Conduct or review a security risk analysis in accordance with the requirements under 45 CFR (a)(1). Comments: Security Risk Assessments (SRAs) are generally not completed by individual EPs, but rather the employer of the EP. Also, while NACHC applauds the availability of free tools and resources from ONC, OCR, and other areas, CMS should recognize these assessments usually require the procurement of specialized technical expertise (e.g. vulnerability and intrusion testing, legal consultation, etc.) which is an added expense to health centers and other provider organizations. In fact, our members report complying with this objective ranges anywhere from $3,000 to $10,000 per year. Recommendation: Revise language to recognize that SRAs are conducted by employers/ organizations, rather than individual EPs. Risk assessments should be required at least once annually (e.g. impractical for a center attesting for the first time in 2017) and not tied to an EHR reporting period. 2. Electronic Prescribing (erx): Require that formulary checks be done automatically, and indicate drugs that ARE covered when the selected drug is not. Proposed Measure: More than 80 percent of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT.

6 Comments: NACHC recommends this functionality be automated and not require providers to click a button in order to run a formulary check. In addition, formulary checks should not only note that the selected drug is NOT covered, but suggest alternative medications which ARE covered. Without these changes, the 80 percent would be quite burdensome for health centers. 3. Computerized Provider Order Entry (CPOE): Clarify the appropriate use of scribes to do Computerized Provider Order Entry (CPOE), including permitting Veteran MAs to continue doing the same tasks they did prior to the introduction of CPOE requirements Proposed Measures: Over 80 percent of medication orders, over 60 percent of laboratory orders, and over 60 percent of diagnostic imaging orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE. Comments: NACHC seeks further clarification on the use of scribes to enter CPOE. It appears that CMS has broadened the scope of who can enter CPOE in the use of such phrases as appropriately credentialed, similar to a medical assistant, we defer to the provider s discretion. Can CMS add an example speaking directly to scribes, in association to the latitude provided in this section? Please note that smaller health centers report experiencing difficulty meeting this measure in Stage 2. Building a radiology interface with the local hospital is often cost prohibitive and difficult to accomplish with limited IT resources. Many smaller or rural health centers report that they are choosing not to pursue Stage 2 because of this measure. Recommendation: NACHC strongly recommends that CMS allow MAs who handled the paper based equivalent of CPOE prior to the Stage 2 Final Rules (September 2012), and who are still employed with the same organization where they were as of September 2012, to be referred to as Veteran MAs and permitted to enter CPOE for MU. Such Veteran MAs were doing this entry long before conditions of credentialed and by an organization other than the employing organization were introduced to the MU rules, and they have a thorough understanding of the organization s workflow, employee competency, and clinical staff. 4. Patient Electronic Access to Health Information (AHI): Ensure that measures are attainable through CEHRT and do not require the purchase of add on products; encourage the aggregation of individual patient s data from multiple EPs into a single site; clarify which accounts are included in the numerator for this measure. Reduce 80 percent of all unique patients seen to 50 percent. Change 24 hours to 72 hours turnaround time. Reduce patient specific educational resources to 10 percent. Consider exclusion where an EP sees predominantly homeless patients without access to a smartphone or computer. Proposed Measures: For more than 80 percent of all unique patients seen by the EP : (1) The patient (or the patient authorized representative) is provided access to view online, download, and transmit his or her health information within 24 hours of its availability to the provider; or

7 (2) The patient (or the patient authorized representative) is provided access to an ONC certified API that can be used by third party applications or devices to provide patients (or patient authorized representatives) access to their health information, within 24 hours of its availability to the provider. The EP, eligible hospital or CAH must use clinically relevant information from CEHRT to identify patient specific educational resources and provide electronic access to those materials to more than 35 percent of unique patients seen by the EP or discharged from the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period. Comments: NACHC believes that the objectives and measures proposed for Patient Electronic Access to Health Information should be attainable by using only CEHRT without it necessitating the need to purchase add on products such as patient portals, expensive interfaces, etc.; that this functionality should come packaged into the core CEHRT functionality. While we applaud the introduction of APIs to support data access and patient exchange, they still will require development of add on products that may come at an additional expense to the center and/or patient. The wording in the measure definition an ONC certified API seems to suggest that there will be an opportunity for multiple companies to develop APIs. While this may represent the possibility for the exchange of information across different portals and EHRs that should be able to seamlessly communicate with each other, some of our Health Centers continue to report challenges faced in exchanging information and communicating across different EHR products for which standards already exist, such as HISPs and direct messaging. Therefore, NACHC strongly recommends and supports the development of a National API and the promotion of a single standard across all EHR platforms. A National API would allow for all vendors, including but not limited to EHR vendors to share information seamlessly and further promote patient and/or patient authorized representative access to data as well as the exchange of data. We also encourage CMS and ONC to explore ways to bring together patient data from disparate sources into a common place as many individual care providers have their own, unique portals which make only their specific data available to the patient. This makes it extremely difficult for a patient to retrieve a holistic view of their personal health information across providers and care settings. NACHC would like more clarity on how APIs would enable this. It would seem that employing a standard approach to accessing patient health information (e.g. requiring providers to only have the API function) has the potential to foster a more convenient, comprehensive, and consistent experience for the patient. Furthermore, requiring notes to be completed within 24 hours is unrealistic for many providers. If the electronic chart is incomplete, the information on the portal will also be incomplete. Reviewing all reports and annotating them in such a way that they are useful to patients simply cannot be reliably accomplished in 24 hours. It is for this reason we strongly recommend adjusting the turnaround time to 72 hours.

8 In addition, as noted by RECs during 2014 and 2015, certified EHRs appear to have different interpretation of what allows a patient s account to appear in the numerator for this measure. NACHC recommends that CMS clarify which accounts count in the numerator so that EPs using different EHRs are consistently reporting this measure. With respect to providing patient specific educational resources, many of the materials provided by EHR vendors is not the needed reading level or designed for patients who speak languages other than English. It is for these reasons we recommend lowering this threshold to 10 percent. 5. Patient Engagement: Recognize the financial and linguistic challenges faced by health center patients, and reduce the degree to which EPs are held accountable for patient behavior that is beyond their control, by lowering the patient engagement thresholds from VDT from 25 percent to 10 percent, secure messaging from 35 percent to 10 percent, and patient generating data from 15 percent to 5 percent. Permit any EP who contributes to a secure patient message (not just the initiating EP) to count that patient in their Secure Messaging measure. Reconsider the measure on incorporating patient generated health data into the EHR. Proposed Measure: During the EHR reporting period, more than 25 percent of all unique patients seen by the EP actively engage with the EHR made accessible by the provider. An EP may meet the measure by either: (1) More than 25 percent of all unique patients (or patient authorized representatives) seen by the EP during the EHR reporting period view, download or transmit to a third party their health information; or (2) More than 25 percent of all unique patients (or patient authorized representatives) seen by the EP during the EHR reporting period access their health information through the use of an ONC certified API that can be used by third party applications or devices. Comments: While NACHC recognizes the important role that EPs play in promoting patient engagement, we do not believe EPs should be responsible for patient behavior for which they have no direct control. Over 70 percent of health center patients live at or below the federal poverty line and therefore do not have the means to have computers or Internet access in their homes to generate patient data, send and receive secure messages, or VDT their information. Moreover, English is the predominant, and in some cases only, currently supported language by EHR vendors, which poses challenges when engaging patients best served in a language other than English. For these reasons, NACHC recommends lowering the thresholds for VDT from 25 percent to 10 percent. Proposed Measure: During the EHR reporting period, for more than 35 percent of all unique patients seen by the EP or discharged from the eligible hospital or CAH during the EHR reporting period, a secure message was sent using the electronic messaging function of CEHRT to the

9 patient (or their authorized representatives), or in response to a secure message sent by the patient Comments: Given the financial, linguistic, and other challenges faced by health center patients (as discussed above), NACHC requests that the threshold for secure messaging be reduced from 35 percent to 10 percent. Furthermore, if there is no recipient available to send a message to via Direct Messaging, it should not be counted against the EP. In addition, NACHC recommends that any provider who contributes to the secure message, not limited to the initiating provider, should have the patient count in his/her numerator for Measure 2 Secure Messaging. It is suggested or expected that the EP s comments be clinically relevant, but we cannot impose constraints on CEHRT with an expectation that this level of input be measured. Examples have been provided by CMS that are helpful; however these examples clearly outline the challenges in how CEHRT would have to differentiate the content of the secure message. Such an expectation is not realistic. Proposed measure: Patient generated health data or data from a non clinical setting is incorporated into the certified EHR technology for more than 15 percent of all unique patients seen by the EP or discharged by the eligible hospital or CAH during the EHR reporting period. Comments: NACHC questions whether patient generated health information should routinely become part of a patient s medical record simply because we have the technology to make this happen. Information provided by non clinical setting (e.g. nutritionists, social workers, physical therapists, other members of a patient s care team) might be deemed appropriate by clinical staff to include in an electronic chart, but should be at the discretion of the EP, not the patient or non clinical personnel or CEHRT. It is expected that for having to meet 2 of 3 of these measures, this one will not be embraced by many. Patient centered communication between and among providers is a worthwhile objective and despite the above comments related to this proposed measure, should not be discouraged. Technical barriers might easily present in meeting this measure. With that said, some of our health centers are already using add on tools to incorporate patient generated health data such as glucose and weight information into the EHR. This data requires screening by the staff prior to including in the medical record, but this data can be helpful in caring for patients provided it is captured in structured data fields. However, today much of this data is being scanned or free texted into the record and therefore standardizing the discrete collection of this data will be critical to its usefulness and practicality. For these reasons, as well as the financial, linguistic, and other challenges faced by health center patients (as discussed above), NACHC requests that the threshold for patient generated data be reduced from 15 percent to 5 percent. 6. Care Transitions and Referrals: Continue the development of the Nationwide Health Information Network, and the alignment of efforts to advance this goal. Ensure that all functionality required for meaningful use is be part of the core EHRT and not dependent on the purchase of third party add on software packages,

10 interfaces, etc. Proposed Measures: For more than 50 percent of transitions of care and referrals, the EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care: (1) Creates a summary of care record using CEHRT; and (2) Electronically exchanges the summary of care record. For more than 40 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP, eligible hospital or CAH incorporates into the patient's record in their EHR an electronic summary of care document from a source other than the provider's EHR system. For more than 80 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP, eligible hospital, or CAH performs clinical information reconciliation. The provider would choose at least two of the following three clinical information sets on which to perform reconciliations: o Medication: Review of the patient's medication, including the name, dosage, frequency, and route of each medication. o Medication allergy: Review of the patient's known allergic medications. o Current Problem list: Review of the patient's current and active diagnoses. Comments: NACHC recognizes the need for requiring standards for the transport mechanism for health information exchange consistently nationwide. It is for this reason NACHC advocates for the continued development of the Nationwide Health Information Network and the alignment of all efforts to advance this goal. With the state, regional, and local HIE so variable and a lack of continued funding, there needs to be more of a focus on a national infrastructure and transport mechanism to support the transfer of data that follows a patient irrespective of where they go. All EHR vendors should be required to integrate with this National Health Information Network in order to obtain base EHR certification, further promoting interoperability and care coordination. NACHC continues to assert that to ensure widespread adoption and future sustainability, the functionality required for the meaningful use program should be part of the core CEHRT and not dependent on the purchase of third party add on software packages, interfaces, etc. For the clinical information reconciliation measure, it follows that the licensed health care professionals and credentialed medical assistants that can complete CPOE should also be permitted the reconciliations required in this measure. Note that medication and problem lists from hospitals are often inaccurate and require the provider to determine what to include in versus what not to include in the EHR. This can be quite time consuming. Summaries of care should be generated automatically so that overly busy providers and staff do not have to create a care summary de novo in every instance that this would be desirable. Recommendation: Continue the development of the Nationwide Health Information Network, and the alignment of efforts to advance this goal and ensure that all functionality required for meaningful use is be part of the core EHRT and not dependent on the purchase of third party add on software packages, interfaces, etc.

11 7. Public Health and Clinical Data Registry Reporting: Clarify that public health measures are to be met by the site, not the EP Finalize the use of the term active engagement in these measures Finalize proposals to create a centralized repository of national, state, and local PHA and CDR readiness, and to develop a national infrastructure to support more standardized reporting of public health measures. Proposed Measures: Immunization Registry Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS). Syndromic Surveillance Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit syndromic surveillance data from a non urgent care ambulatory setting for EPs, or an emergency or urgent care department for eligible hospitals and CAHs (POS 23). Case Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit case reporting of reportable conditions. Public Health Registry Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit data to public health registries. Clinical Data Registry Reporting: The EP, eligible hospital, or CAH is in active engagement to submit data to a clinical data registry. Comments: NACHC applauds the change from the use of the term ongoing submission to active engagement which more accurately reflects the nature of a relationship between sites and PHAs/CDRs. Many of our members report that registries are NOT or are minimally functional in their states. NACHC thinks that Public Health measures should be met by site, not EP. Any EP working at a site that meets the requirements should be eligible to attest Yes, regardless as to whether that EP administers immunizations, for example. An EP that is licensed and capable of administering an immunization, but does not in their current scope of work administer immunizations, is still a provider who is available to the security of Public Health should an epidemic present and that EP is called upon to health the system with administering emergent immunizations. It is important the EP s site is capable, not whether the EP actually administers any immunizations during a MU reporting period. It is fair that exclusion for a measure does not count toward the total requirement of three measures. NACHC also welcomes the creation of a centralized repository of national, state, and local PHA and CDR readiness, as well as the development of a national infrastructure to support more standardized reporting of immunizations, syndromic surveillance, cancer, public health and case reporting. NACHC is concerned that the public health infrastructure may not be keeping up with the demand the new EHR certification requirements are weighing on it. Recommendations: Clarify that public health measures are to be met by the site, not the EP. Finalize the use of the term active engagement in these measures. Finalize proposals to

12 create a centralized repository of national, state, and local PHA and CDR readiness, and to develop a national infrastructure to support more standardized reporting of public health measures. *** Thank you for the opportunity to comment on this important proposed rule. NACHC staff, and our member health centers, would be happy to provide the Department with any further information that would be beneficial. To initiate a discussion, please contact me at or cmeiman@nachc.org. Sincerely, Colleen P. Meiman, MPPA Director, Regulatory Affairs National Association of Community Health Centers

13 Attachment: Overview of Section 330 Health Centers For 50 years, Health Centers have provided access to quality and affordable primary and preventive healthcare services to millions of uninsured and medically underserved people nationwide, regardless of their ability to pay. At present there are almost 1,300 health centers with more than 9,300 sites. Together, they serve over 22 million patients, including nearly seven million children and more than a quarter million veterans. Health centers provide care to all individuals, regardless of their ability to pay. All health centers provide a full range of primary and preventive services, as well as services that enable patients to access health care appropriately (e.g., translation, health education, transportation.) A growing number of Health Centers also provide dental, behavioral health, pharmacy, and other important supplemental services. To be approved by the Federal government as a Health Center, an organization must meet requirements outlined in Section 330 of the Public Health Service Act. These requirements include, but are not limited to: Serve a federally designated medically underserved area or a medically underserved population. Some Health Centers serve an entire community, while other target specific populations, such as persons experiencing homelessness or migrant farmworkers. Offer services to all persons, regardless of the person s ability to pay. Charge no more than a nominal fee to patients whose incomes are at or below the Federal Poverty Level (FPL) Charge persons whose incomes are between 101% and 200% FPL based on a sliding fee scale Be community based, with the majority of their governing board of directors composed of their patients Most Section 330 Health Centers receive Federal grants from the Bureau of Primary Health Care (BPHC) within HRSA. BPHC s grants are intended to provide funds to assist health centers in covering the otherwise uncompensated costs of providing care to uninsured and underinsured indigent patients, as well as to maintain the health center s infrastructure. Patients who are not indigent or who have insurance, whether public or private, are expected to pay for the services rendered. In 2013, on average, the insurance status of Health Center patients is as follows: 41% are Medicaid recipients 35% are uninsured 14% are privately insured 8% are Medicare recipients. No two health centers are alike, but they all share one common purpose: to provide primary health care services that are coordinated, culturally and linguistically competent, and community directed care to uninsured and medically underserved people.