Less than 10% of the patient population in Community Health Centers are Medicare patients.  

Even in states with significant senior populations such as Florida, Arizona and Texas, as few as 1 or 2 percent of Community Health Center patients have Medicare.

On the surface, this may seem normal since CHCs tend to care for patients who don’t have health insurance. But, when health centers don’t focus on attracting Medicare patients they overlook a neglected and often very needy group of patients.  In fact, Congress has developed Medicare’s funding for Federally Qualified Health Centers in such a way that many (if not most) low to moderate income Medicare patients can be better served in a Community Health Center environment than a typical “fee for service” office.

Let’s explore some examples:

  • Prospective Payment System pays a flat rate for all Medicare services.

The PPS rate for patients is a flat fee charged by Federally Qualified Health Centers (FQHC).  FQHCs set their own charges for the services they provide and determine which services to include in the bundle of services associated with each FQHC G-code. However, the rate determined by congress that can be billed averages out to be approximately $160 for every visit.  This flat rate give FQHCs unique opportunities to serve Medicare patients in a way that no one else can.

  • Transportation.

FQHCs are in the unique position of being allowed, and in some cases required, to provide transportation to and from FQHC appointments.  Fee for Service practices are typically not allowed to offer this service as it may be considered an inducement.  A tremendous number of Medicare patients do not seek care on a regular basis simply because they do not have reliable transportation.  FQHCs can solve this problem.

  • 340B Prescriptions.

Prescriptions written by an FQHC provider automatically qualify for that FQHC’s 340B program.  Medicare patients are the highest users of prescription medications and frequently can not afford them so they either go without, use them improperly, or go without other necessities in order to pay for their medicines.  The 340B program can solve this problem.

Developing a Program for Medicare Patients:

Medicare patients (especially low to moderate income patients) often need supports wrapped around them to ensure they maintain healthy lifestyles, prevent disease, self-advocate and improve communication with their providers.  Medicare has developed a series of services to ensure systems are in place to take care of these patients.  Unfortunately, these services are often very low reimbursement and Fee for Service providers are unable to support these programs in their practice.  This is not the case for FQHCs whose PPS rates make all services equally reimbursed.  Here are examples of services that FQHCs can offer their Medicare patients.

  • Chronic Care Management:  The first service I will mention actually doesn’t qualify for the PPS rate but does offer an opportunity to establish a foundation of care.  Developing a CCM program allows you to hire qualified nurses to supervise the care of your most ill patients.  Reimbursement for this service is approximately $40 per patient per month and requires 20 minutes per month spent on each patient.
  • Introduction to Medicare (IPPE) and Annual Wellness Visit:  The IPPE and AWV are the foundation for preventive care for your practice.  For FQHCs the reimbursement for this service is $160 plus 1.34% making the reimbursement approximately $212 per patient.  This shows just how important these visits are to Medicare.  These visits are the time your practice can develop a plan of action that will help your provider’s care for their Medicare patients.  All Medicare patients (not on hospice) qualify for the AWV/IPPE and even nursing home patients should have this planning time allotted for them.  This is also the perfect time to screen your patients for inclusion in CCM.
  • Screenings: There are a variety of screenings the AWV/IPPE is designed to find and inform your provider and patients when they are due.  Examples include the cancer screenings, immunizations and other preventive services.  It is imperative that when you find these services during the AWV, you give your patient a list of when these services are due (required by both the AWV and IPPE.)  If your patient qualifies for CCM services, their designated nurse can ensure the patient keeps track of these times and encourages them to meet these dates.  These screenings triggered by the AWV also help meet quality measures.
  • Other Preventive Services: Once your plan of action is completed, your program should expand to offer a variety of behavioral management services such as the following:
    1. Weight Loss Counseling – Called the Intensive Behavioral Therapy for Obesity, this service offers up to 20 visits annually to help the patients lose weight.  The requirement for this visit has USPSTF’s 5 A’s requirement.  
    2. Healthy Heart Visit – Called the Intensive Behavioral Therapy for Cardiovascular Disease, this service is an annual visit that enables practices to determine if patient needs further cardiovascular care.  The CDC estimates that ¼ of all deaths from heart attacks and strokes are preventable.  Following USPSTF’s 5As allows practices to work on preventing those attacks.
    3. Depression Screening – Approximately 5% of all patients screened during their Wellness Visit or Introduction to Medicare visit are expected to show signs of depression needing further screening.  An in-depth Depression screening is a good way for practices to ensure their patients who show signs of depression are getting those needs met.
      • Cognitive Screening – Medicare doesn’t offer codes to reimburse FQHCs for cognitive testing.  That being said, if patients are showing cognitive decline, practices should first check for depression before referring them for neurological testing.  Using depression screening codes are an appropriate way of ruling out depression before making those referrals.  Although, not billable through FQHC PPS, practices can at their own cost concurrently do a cognitive screening such as the MOCA or SLUMS with a depression screening.

It would be a boon to Medicare patients nationwide if Community Health Centers began to focus their efforts on creating wellness centers designed to support the unique needs of their Medicare senior population.

It would also be a financial boon for Community Health Centers to increase utilization of their services to the Medicare population. Not only does this increase the reach of care by the CHC but it also increases reimbursements and that could go a long way in leveling the the political ups and downs associated with government grants and funding programs.