Health Centers, which include HCH programs, generally receive federal grants from the HHS Health Resources and Services Administration (HRSA) to provide comprehensive primary care and preventive services to low-income people in underserved communities. These Health Centers generally also receive Medicaid and Medicare reimbursements as FQHCs.41 States are required to provide FQHC services in the Medicaid program. FQHCs provide primary and preventive health care to individuals who are homeless and others. In addition, FQHCs are qualified to furnish mental health and substance use disorder services.
The majority of Health Center patients have incomes below the FPL. Before 2014, about 40 percent of Health Center patients were Medicaid beneficiaries but more than one-third of them were uninsured. Many uninsured patients served by Health Centers before 2014 became eligible for Medicaid or federally subsidized insurance coverage beginning in 2014.42
HCH programs receive 8.7 percent of total federal funding for Health Centers. The more than 200 HCH programs include grantees operating in all 50 states, the District of Columbia, and Puerto Rico. Some programs are operated by Health Centers that also receive federal funding to serve a general, medically underserved population in a defined service area, while some programs receive federal grant funding to target services to a specific designated population, such as homeless people. In 2012, programs nationwide served over 835,000 patients, of whom approximately 90 percent had incomes at or below the FPL.43
HCH programs funded under Section 330(h) of the Public Health Service Act provide services to people experiencing homelessness, and may continue to provide services for up to 12 months after a formerly homeless person moves into housing. The definition of homelessness used by HHS for purposes of eligibility for HCH services is broader than HUD's definition of homelessness, and includes people who are staying in hotels or doubled up with other households, in addition to people living on the streets, in shelters, and in transitional housing programs. Language included in the FY 2012 Appropriations Act allows HCH grantees flexibility to consider residents of PSH or other housing programs that are targeted toward homeless populations as "homeless" for purposes of continued eligibility for services.44
4.2.1. FQHC Services
FQHCs provide preventive and primary care health services, as required by their federal grant funding. These include, at a minimum, services provided by physicians, physician assistants, nurse-practitioners, certified nurse-midwives, and clinical psychologists or clinical social workers and services and supplies furnished incident to these practitioners' services. FQHCs must also offer "any other ambulatory services" that are included in the state's Medicaid state plan, so additional services such as dental services may also be offered. FQHCs are required to provide health care to all individuals regardless of their ability to pay and are required to be located in geographic areas that have few health care providers. Qualifying Health Centers are reimbursed by Medicaid for care included in their state's Medicaid FQHC benefit that they provide to patients who are Medicaid beneficiaries.
In addition to health services provided by physicians and physician extenders, Health Centers must provide in their package of required primary health services referrals to providers of "other health-related services, including substance use disorder and mental health services." This referral requirement is a minimum; many Health Centers directly provide behavioral health services, including services delivered by psychiatrists, licensed clinical social workers, and other clinicians and paraprofessional staff. Health Centers are also required to provide services that Medicaid is not required to reimburse, including preventive dental services, case management, and services that enable patients to access health services such as transportation and translation.
Health Care for the Homeless Programs
HCH programs have some additional requirements. In addition to basic primary and preventive health services, they must also offer the following:
Substance abuse treatment, which is often offered through partnerships with other programs, but some HCH programs and other Health Centers offer some of these services directly.
Case management services.
Services that enable people to use other Health Center services (e.g., outreach, transportation, and translation services).
Patient education regarding the availability and proper use of health services.
Mental health services are not a required component of HCH services under federal program rules, but most programs deliver mental health services directly or through partnerships with other providers, and all are expected to make referrals to specialty services including those for mental health care. The text box below shows how one HCH Program, in Skid Row Los Angeles, organizes itself to provide integrated services to the area's many homeless people and people living in PSH.
|JWCH, an FQHC, operates the Center for Community Health in the heart of Skid Row in Los Angeles. The Center is designed to support the delivery of integrated services including medical, mental health, substance abuse, clinical pharmacy, dental, and other services and supports. The building is designed to support interdisciplinary teams working in "pods," so that a primary care provider can walk a client over to a mental health provider for assessment on the same day, and team members can consult with one another. Each team (i.e., each pod) is responsible for a group of patients and uses weekly case conferencing to coordinate care for those with the most intensive needs. In addition to care provided in the JWCH clinic, the program sees patients in clinics located in PSH buildings.|
When HCH programs provide covered services to Medicaid enrollees, the programs are required to bill Medicaid for reimbursement, but before 2014 most patients were uninsured so the programs could not bill Medicaid for their care. In 2012, over 61 percent of HCH adult patients in the United States did not have any public or private health insurance, and 29 percent were covered by Medicaid.45 In the states that chose to implement the expansion of Medicaid eligibility in 2014 under the provisions of the Affordable Care Act, most patients became eligible for Medicaid coverage based on their low incomes.
Health Centers and HCH programs provide services linked to housing through one or more of the following models:
Delivering on-site services through home visits or satellite clinics located in or near PSH buildings.
Operating a clinic that is easily accessible by PSH residents and designed to meet their needs.
Partnering with a mental/behavioral health service provider to conduct outreach to vulnerable homeless people and deliver integrated care to people experiencing homelessness and residents of scattered-site PSH, creating a multi-disciplinary team of primary and behavioral health care providers.
Engaging "frequent users" of emergency room care and people experiencing homelessness who are being discharged from hospitals and linking them to permanent housing.
4.2.2. FQHC Providers
Medicaid reimburses qualifying Health Centers and HCH programs for visits with specific types of clinicians, based on a per-visit rate.46 Qualifying providers include:
- physicians, including primary care providers and specialists such as psychiatrists;
- mid-level practitioners, including physicians' assistants and nurse-practitioners; and
- licensed clinical social workers and clinical psychologists.
In addition to Medicaid reimbursement, most FQHCs receive federal grant funding administered by HRSA's Bureau of Primary Care. These grants are authorized by Section 330 of the Public Health Service Act.47 Health Centers must obtain HRSA approval for the scope of Section 330 grant-related projects; the "scope of project" specifies the services, sites, providers, target population(s), and service areas for which federal grant funds have been approved.
4.2.3. FQHC Service Settings
A Health Center's scope of project for HRSA also defines the service sites and services that qualify for Medicaid and Medicare reimbursement, based on the established payment methodology for FQHCs. For FQHCs, a service site is any location where a Health Center grantee provides primary and preventive care services to a defined service area or target population, either directly or through a subrecipient or established arrangement. Particularly for vulnerable populations, including people who are experiencing homelessness and those who are living in PSH, FQHC services may be delivered "outside the four walls" of the Health Center. Service sites may be permanent, seasonal, or intermittent, or delivered by a mobile van, as appropriate to meet the needs of the target population. A service site may provide comprehensive primary care services or may provide a single service such as oral or mental health services.
Permanent sites are open year-round on a regularly scheduled, full-time or part-time basis. There is no minimum number of hours that services must be available at a site. Some Health Centers and HCH programs operate permanent sites located in or adjacent to PSH, and these sites may operate on a full-time or part-time basis.
Seasonal sites operate for only part of the year, and are designed to meet the needs of patients who may be mobile and working or living in a location for only part of the year.
Intermittent sites provide direct primary care services but operate for a short period of time at locations that change frequently to meet the needs of mobile populations, including migrant workers or people experiencing homelessness. For example, potential locations for intermittent sites include shelters, soup kitchens, and encampments.
A fully equipped mobile van is considered a service site if it is staffed by Health Center clinicians and is providing direct primary medical care or oral health services at various locations.
Health Centers also often provide activities within their scope of project that are delivered at locations that do not meet the definition of a service site because they are mobile or are conducted on an irregular schedule and offer a limited set of services drawn from the full complement of services defined by the scope of project. Locations may include places where clinicians and project staff go from time to time to seek out, engage, and serve people who are covered under the scope of project and eligible to receive services but who are unlikely to access services at a Health Center, at least at first. These locations, which are outside of the walls of an established site, could include settings in which clinicians engage and provide services to people who are experiencing homelessness or tenants of PSH. Specifying an exhaustive list of such activities and locations as part of a Health Center's scope of project is impractical; a more functional approach is to include general categories of locations and the activities likely to be offered there as part of the approved scope of project.48