Chapter 4: Required and Additional Health Services

Note: This chapter contains language that was revised based on the Bipartisan Budget Act of 2018. View the revisions (PDF - 582 KB).

In this chapter:

• Authority
• Requirements
• Demonstrating compliance
• Related considerations

Authority

Section 330(a)-(b), Section 330(h)(2), and Section 330(k)(3)(K) of the PHS Act; and 42 CFR 51c.102(h) and (j), 42 CFR 56.102(l) and (o), and 42 CFR 51c.303(l)

Requirements

• The health center must provide the required primary health services listed in section 330(b)(1) of the PHS Act.
• A health center that receives a Health Center Program award or look-alike designation under section 330(h) of the PHS Act to serve individuals experiencing homelessness must, in addition to these required primary health services, provide substance use disorder services.
• The health center may provide additional (supplemental) health services that are appropriate to meet the health needs of the population served by the health center, subject to review and approval by HRSA.
• All required and applicable additional health services must be provided through one or more service delivery method(s): directly, or through written contracts and/or cooperative arrangements (which may include formal referrals).
• A health center which serves a population that includes a substantial proportion of individuals of limited English-speaking ability must:
  • Develop a plan and make arrangements for interpretation and translation that are responsive to the needs of such populations for providing health center services to the extent practicable in the language and cultural context most appropriate to such individuals; and
  • Provide guidance to appropriate staff members with respect to cultural sensitivities and bridging linguistic and cultural differences.

Demonstrating compliance

A health center would demonstrate compliance with these requirements by fulfilling all of the following:

1. The health center provides access to all services included in its HRSA-approved scope of project¹ (Form 5A: Services Provided) through one or more service delivery methods,² as described below:³
   • Direct: If a required or additional service is provided directly by health center employees⁴ or volunteers, this service is accurately recorded in Column I on Form 5A: Services Provided, reflecting that the health center pays for and bills for direct care.
   • Formal Written Contract/Agreement:⁵ If a required or additional service is provided on behalf of the health center via a formal contract/agreement between the health center and a third party (including a subrecipient),⁶ this service is accurately recorded in Column II on Form 5A: Services Provided, reflecting that the health center pays for the care provided by the third party via the agreement. In addition, the health center ensures that such contractual agreements for services include:
     • How the service will be documented in the patient’s health center record; and
     • How the health center will pay for the service.
   • Formal Written Referral Arrangement: If access to a required or additional service is provided and billed for by a third party with which the health center has a formal referral arrangement, this service is accurately recorded in Column III on Form 5A: Services Provided, reflecting that the health center is responsible for the act of referral for health center patients and any follow-up care for these patients provided by the health center subsequent to the referral.⁷ In addition, the health center ensures that such formal referral arrangements for services, at a minimum, address:
     • The manner by which referrals will be made and managed; and
     • The process for tracking and referring patients back to the health center for appropriate follow-up care (for example, exchange of patient record information, receipt of lab results).
2. Health center patients with limited English proficiency are provided with interpretation and translation (for example, through bilingual providers, on-site interpreters, high quality video or telephone remote interpreting services) that enable them to have reasonable access to health center services.
3. The health center makes arrangements and/or provides resources (for example, training) that enable its staff to deliver services in a manner that is culturally sensitive and bridges linguistic and cultural differences.

Related considerations

The following points describe areas where health centers have discretion with respect to decision-making or that may be useful for health centers to consider when implementing these requirements:

• The health center governing board determines which, if any, additional health services to offer in order to meet the health needs of the population served by the health center (subject to review and approval by HRSA).
• The health center determines how to make services accessible in a culturally and linguistically appropriate manner,⁸ based on its patient population.
• The health center determines the level or intensity of required and additional services, as well as the method for delivering these services, based on factors such as the needs of the population served, demonstrated unmet need in the community, provider staffing, and collaborative arrangements.
• The health center may, through policies and operating procedures, prioritize the availability of additional services within the approved scope of project to individuals who utilize the health center as their primary care medical home.

Footnotes

^1. In accordance with 45 CFR 75.308 (Uniform Administrative Requirements: Revision of Budget and Program Plans), health centers must request prior approval from HRSA for a change in the scope or the objective of the project or program (even if there is no associated budget revision requiring prior written approval). This prior approval requirement applies, among other things, to the addition or deletion of a service within the scope of project. These changes require prior approval from HRSA and must be submitted by the health center as a formal change in scope request. See Scope of Project website for further details on scope of project, including descriptions of the services listed on Form 5A: Services Provided available at: Form 5A: Service Descriptors (PDF - 315 KB).

^2. The Health Center Program statute states that health centers may provide services “either through the staff and supporting resources of the center or through contracts or cooperative arrangements.” 42 U.S.C. 254b(a)(1) The Health Center Program Compliance Manual utilizes the terms “Formal Written Contract/Agreement” and “Formal Written Referral Arrangement” to refer to such “contracts or cooperative arrangements.” For more information on documenting service delivery methods within the HRSA-approved scope of project on Form 5A: Services Provided, see: Form 5A Column Descriptors (PDF - 110 KB).

Other Health Center Program requirements apply when providing services through contractual agreements and formal referral arrangements. Such requirements are addressed in other chapters of the Manual where applicable.

^3. See Chapter 9: Sliding Fee Discount Program for more information on sliding fee discount program requirements and how they apply to the various service delivery methods.

^4. For purposes of the HRSA-approved scope of project (Form 5A: Services Provided), HRSA/BPHC utilizes Internal Revenue Service (IRS) definitions to differentiate contractors and employees. Typically, an employee receives a salary on a regular basis and a W-2 from the health center with applicable taxes and benefit contributions withheld.

^5. See Chapter 12: Contracts and Subawards for more information on program requirements around contracting.

^6. For purposes of the HRSA-approved scope of project (Form 5A: Services Provided), services provided via “contract/formal agreement” are those provided by practitioners who are not employed by or volunteers of the health center (for example, an individual provider with whom the health center has a contract; a group practice with which the health center has a contract; a locum tenens staffing agency with which the health center contracts; a subrecipient organization). Typically, a health center will issue an Internal Revenue Service (IRS) Form 1099 to report payments to an individual contractor. See the FTCA Health Center Policy Manual (PDF - 406 KB) for information about eligibility for Federal Tort Claims Act (FTCA) coverage for covered activities by covered individuals, which extends liability protections for eligible “covered individuals,” including governing board members and officers, employees, and qualified individual contractors).

^7. For purposes of the HRSA-approved scope of project (Form 5A: Services Provided), access to services provided via “formal referral arrangements” are those referred by the health center but provided and billed for by a third party. Although the service itself is not included within the HRSA-approved scope of project, the act of referral and any follow-up care provided by the health center subsequent to the referral are considered to be part of the health center’s HRSA-approved scope of project. For more information on documenting service delivery methods within the HRSA-approved scope of project on Form 5A: Services Provided, see: Form 5A Service Column Descriptors (PDF - 110 KB).

^8. See the National Standards for Culturally and Linguistically Appropriate Services (CLAS) published by the U.S. Department of Health and Human Services at Think Cultural Health. For additional information and guidance. Additional cultural/linguistic competency and health literacy tools, resources and definitions are available online at HRSA: Culture, Language, and Health Literacy and HRSA: Health Literacy.