Primary Care Fund (PCF) Grant Program Background
In accordance with Section 21 of Article X (Tobacco Taxes for Health-Related Purposes) of the State Constitution, an increase in Colorado's tax on cigarettes and tobacco products became effective January 1, 2005 and created a cash fund that was designated for health-related purposes. House Bill 05-1262 divided the tobacco tax cash fund into separate funds, assigned 19% of the moneys to establish the Primary Care Fund, set forth how the funds will be allocated and designated the Department of Health Care Policy and Financing (the Department) as the administrator of the Primary Care Fund.
The Primary Care Fund provides an allocation of moneys to health care providers that make basic health care services available in an outpatient setting to residents of Colorado who are considered medically indigent. Moneys shall be allocated based on the number of medically indigent patients served by one health care provider in an amount proportionate to the total number of medically indigent patients served by all health care providers who qualify for moneys from this fund.
What services do I need to provide to qualify for PCF?
To qualify for PCF the agency must provide or arrange for the provision of services to persons of all ages on a year-round basis (consecutive 52-week period) for the following comprehensive primary care services:
- Basic, entry-level health care provided by health care practitioners or non-physician health care practitioners that is generally provided in an outpatient setting.
- Primary health care,
- Maternity care, including prenatal care, preventive, developmental, and diagnostic services for infants and children,
- Adult preventive services,
- Diagnostic laboratory and radiology services,
- Emergency care for minor trauma,
- Pharmaceutical services, and
- Coordination and follow-up for hospital care.
What does “arrange for the provision of services for persons of all ages” mean?
A clinic should have an established referral relationship with health care providers for any of the Comprehensive Primary Care services not directly provided by the provider. An entity in a rural area may be exempt from this requirement if they can demonstrate that there are no providers in the community to provide one or more of the Comprehensive Primary Care services.
An Established Referral Relationship is a formal, written agreement in the form of a letter, a memorandum of agreement or a contract between two entities which includes:
- The Comprehensive Primary Care and/or products (e.g., pharmaceuticals, radiology) to be provided by one entity on behalf of the other entity.
- Any applicable policies, processes or procedures.
- The guarantee that referred Medically Indigent Patients shall receive services on a Sliding Fee Schedule or at no charge; and
- Signatures by representatives of both entities.
Which patients can I include in my unduplicated patient count?
Patients that you may count on the PCF application are those who have had a face-to-face visit/encounter and received at least one of the services under the definition of comprehensive primary care during the applicable calendar year but you may not count the same patient more than once. The following patients are not allowable in the unduplicated patient count:
- Counting a patient more than once if the same patient returns for additional services (e.g., medical or dental) and/or products (e.g., pharmaceuticals) during the applicable calendar year, or
- Duplicating a patient if the payment source designation changed during the applicable calendar year
Patients who received services from any of the following are not allowable:
- Outreach event, community education program, nurse hotline, or other types of community-based events or programs and were not documented on an individual basis,
- Large-scale efforts such as mass immunization programs, screening programs, and health fairs, or
- Those whose only contact with the applicant agency is to receive Special Supplemental Nutrition Program for Women, Infants, and Children (WIC Program) counseling and vouchers are not users and the contact does not generate an encounter.
Can I include telemedicine services?
On August 30, 2020, the Medical Services Board approved the Department's request to lift the "face-to-face" restriction stated in 10 CCR 2505-10 8.950.2.T.
Therefore, patients that received a telehealth service delivery prior to August 30, 2020 may be included on the PCF application form if the telehealth visit was conducted through a face-to-face delivery such as through video and not through the phone.
Effective August 30, 2020, the Primary Care Fund rule 8.950.2.T was modified to lift the "face-to-face" restriction allowing for all means of telehealth service deliveries.
What is a Freeze Date?
The freeze date will act as a point of time in which data is fixed and definite so that a count can be made. The patient's visit closest to your freeze date is the source designation used in the application. The unduplicated patient count should be calculated on a specific point-in-time occurring between the end of the applicable calendar year and prior to the submission of the application. For example, the FY 2022-23 PCF application due May 20, 2022, includes data from the calendar year 2021. In this example, your freeze date could be anywhere from December 31, 2021 - May 19, 2022.
What is the PCF award based on?
The PCF awards are based on the uninsured population of patients whose Federal Poverty Level (FPL) is below 200%. Those patients that are with Colorado Indigent Care Program (CICP) may be included in this population. PCF funding does not include patients who were enrolled in:
- Medicaid (primary or secondary)
- Any other type of reimbursement for health care costs by a government program (i.e., Medicare, Social Security, Veterans Administration, Military Dependency [TRICARE or CHAMPUS], United States Public Health Service). NOTE: This number should not include CICP clients.
- Women's Wellness Connection (WWC) Program
- A patient seen under the WWC is not subject to a Sliding Fee Schedule payment and their services are being paid for by the WWC program. Therefore, WWC meets the definition of Third-Party Payer and these patients should be categorized under Step 2c: any other type of reimbursement for health care costs by a government program.
- Women's Wellness Connection (WWC) Program
- Any other Third-Party Payer not mentioned above (such as private insurance).
What constitutes a Third-Party Payer?
Under 10 CCR 2505-10, Section 8.950.2.Q., a Third-Party Payer is defined as:
"Any individual, entity or program with a legal obligation to pay for some or all health-related services rendered to a patient." Examples include the Medical Assistance Program, the Children's Basic Health Plan, Medicare, commercial, individual or employment-related health insurance, court-ordered health insurance (such as that required by non-custodial parents), workers' compensation, automobile insurance, and long-term care insurance. The Colorado Indigent Care Program is not considered a Third-Party Payer and payments received from the Colorado Indigent Care Program are not considered Third Party Payments."
Note that the definition of Medically Indigent Patient is not limited to those who do not have public or private health insurance, but also those without "any other governmental reimbursement for health care costs" and where "there is no Third-Party Payer." Also note that the definition of Third-Party Payer is "any individual, entity or program with a legal obligation to pay for some or all health-related services rendered to a patient" and that some of the examples are not health insurance plans. Third Party Payer is not limited to health insurance plans or to those plans or programs that provide coverage for the full array of comprehensive primary care services.
To meet the qualifications of a Primary Care Fund provider the provider must accept all patients regardless of their ability to pay and use a Sliding Fee Schedule for payments or do not charge Medically Indigent Patients for services (10 CCR 2505-10 8.950.2.N.1.). The Sliding Fee Schedule is a tiered co-payment system that determines the level of patient's financial participation and guarantees that the patient financial participation is below usual and customary charges. Factors considered in establishing the tiered co-payment system shall only be financial status and the number of members in the patient's family unit (10 CCR 2505-10 8.950.2.P.).
As a result, if a provider is charging patients on a Self-Pay rate that is outside of the provider's Sliding Fee Schedule or is not at a zero dollar rate those patients are not to be included in the final Medically Indigent Patient count and should be eliminated during the methodology process on the Primary Care Fund application.
What supporting documentation do I need to provide in the PCF application?
The following documentation is required for the PCF application:
Sliding Fee Scales and Co-Payments
- A sliding fee scale is a tiered co-payment system that determines the level of patient financial participation and guarantees that the patient financial participation is below usual and customary charges. Factors considered in establishing the tiered co-payment system shall only be financial status and the number of members in the patient's family unit. In the case of pharmaceutical services, formal arrangements with pharmaceutical companies to provide prescriptions at a minimal charge or at no fee can replace a sliding fee scale as long as all classes of prescription medications are covered.
- There should be a minimum of two sliding fee scales provided due to the change in the FPL guidelines at the end of January. Also include the corresponding co-payments for each sliding fee scale. This documentation should support the patient counts in your application
Certification by Outside Entity
- The numbers in the unduplicated patient count provided shall be verified by an outside entity prior to the submission of the PCF application response. The outside entity will also verify that the sliding fee scale has been administered correctly. The Department requires a minimum of 25 applications, unless notified differently to be sampled. This is a requirement from every provider for every application. Certification and Licenses
- Active certification or licensure from the Joint Commission or Accreditation Association for Ambulatory Health Care (AAAHC)
- If you do not have certification or licensure from the Joint Commission or AAAHC then the applicant must supply a Quality Assurance Program in the PCF application.
When do I need to complete the entire PCF application?
An agency must complete the entire application if you are a new applicant. In addition, returning applicants must complete the entire application every three years.
How often will I go through a data validation audit?
Recipients of PCF funding can expect to go through the audit process approximately every three years by the Department and their vendor.
How long do I need to keep my records?
Access to files and documentation supporting the data in your application shall be made available for a period of 5 - 7 years following the submission of the application.
Are there financial impacts from audit findings?
If the data validation review uncovers over-reported numbers in your application, you can expect a financial adjustment reflecting those findings in your fourth quarter payment.
How do PCF payments work?
The awarded amount is allocated based on the number of medically indigent patients served and the initial budget appropriation of tobacco tax revenue. PCF payments are dispersed in quarterly installments beginning the fall of the grant fiscal year. Recipients of PCF funding can expect their fourth quarter payment to be adjusted to the final tobacco tax revenue received in the grant fiscal year and final data validation findings.
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