FQHC glossary

A federal program that requires pharmaceutical manufacturers to offer discounted prices on drugs to covered entities like FQHCs. This can save millions annually on medication costs.

A network of healthcare providers (hospitals, clinics, FQHCs) aligned to jointly manage patient populations and improve outcomes under value-based contracts. Shares savings if quality improves and costs decrease.

Reimbursement methods other than fee-for-service, such as capitation or value-based payments where providers share risk and potential savings. FQHCs increasingly use APMs.

A yearly preventive visit covered by Medicare that includes health risk assessment, personalized prevention plan, and screening referrals. FQHCs use AWVs to improve quality metrics and identify care gaps proactively.

Healthcare services addressing mental health conditions (depression, anxiety) and substance use. Many FQHCs integrate behavioral health into primary care to address SDOH and improve outcomes.

A regional organization contracted by Medicaid to manage behavioral health services, approvals, and claims. FQHCs often coordinate with BH-ASOs to deliver mental health care.

A Medicare billing code set (99484, 99492-99494) that reimburses FQHCs for integrating behavioral health services into primary care. Also refers to the broader clinical model of co-locating mental health within FQHC settings.

California's multi-year initiative to strengthen Medicaid by expanding behavioral health services, addressing social determinants of health, and improving care coordination through enhanced programs like ECM.

A CalAIM component providing Medi-Cal funding for social services like housing assistance, nutrition, and transportation—addressing social determinants of health. FQHCs refer patients to these supports.

A California Department of Public Health (CDPH) project. It supports local health jurisdictions and other partners in planning for the health effects of climate change, using the CDC's BRACE framework.

The organized process of managing a patient's care across multiple providers, settings, and services. In FQHCs, care coordinators connect patients to specialists, social services, and follow-up appointments.

A Medicare care-management service for patients with two or more chronic conditions expected to last at least 12 months, or until death, that place the patient at significant risk. It includes a comprehensive care plan and ongoing coordination and is distinct from CalAIM programs that may use similar care-management language.

A Medicare billing program (CPT 99490, 99491) that reimburses FQHCs for non-face-to-face care coordination for patients with two or more chronic conditions. Requires 20+ minutes of staff time per month. Distinct from CalAIM's Complex Care Management.

A large California nonprofit foundation that funds health policy research and healthcare initiatives. Publishes key analyses on FQHC funding impacts and healthcare access.

A frontline health professional who bridges clinics and communities—conducting outreach, health education, care coordination, and social support. CHWs are integral to FQHC service delivery in California.

Federal standards requiring healthcare organizations to provide culturally competent and linguistically accessible services. CLAS standards guide FQHC interpretation, translation, and cultural competency training.

The federal agency that administers Medicare and Medicaid programs and sets reimbursement rates for FQHCs. CMS regulations directly impact FQHC revenue and operations.

The state trade association representing California's FQHCs. Advocates for FQHC policy, funding, and workforce issues at the state level.

California's state agency that administers Medi-Cal (California's Medicaid program) and contracts with health plans, BH-ASOs, and FQHCs. Sets state-level healthcare policy affecting FQHC operations.

California's state public health agency. Works with FQHCs on disease surveillance, emergency response, vaccination programs, and health equity initiatives.

A Medi-Cal program that pays FQHCs to coordinate care for high-risk patients through home visits, care planning, and referrals to social services. Eligible patients include those with serious health conditions or social barriers to health.

A digital system that stores patient medical records, test results, medications, and visit history. Most FQHCs use EHRs for clinical care, billing, and quality reporting.

A Medicaid benefit requiring comprehensive preventive care and treatment for children under 21. FQHCs provide EPSDT screening and ensure access to specialty care referrals.

The federal government's share of Medicaid spending for a state. Higher FMAP means more federal funding for Medicaid services. California's FMAP affects FQHC Medicaid revenue.

The income threshold set by the federal government used to determine eligibility for programs like Medicaid and sliding fee scales. FQHCs offer sliding fee discounts to patients at or below 200% FPL, and they serve every patient regardless of income or ability to pay.

A Medicare and Medicaid provider type that includes Health Center Program award recipients, HRSA-designated look-alikes, and certain tribal or urban Indian outpatient programs. Look-alikes meet Health Center Program requirements but do not receive Health Center Program funding.

A measure of workforce size. One FTE equals one full-time employee (40 hours/week). Part-time staff are counted as fractions (e.g., 0.5 FTE for 20 hours/week).

Federal reconciliation legislation enacted as Public Law 119-21 on July 4, 2025. It made broad changes to taxes and federal spending, including Medicaid provisions. Use the enacted law and current agency implementation guidance when evaluating a specific effect; it is no longer a proposed bill.

A California state department, formerly the Office of Statewide Health Planning and Development (OSHPD), whose portfolio includes health workforce, facility, financing, and health-information programs.

A coding system used by Medicare and managed care plans to classify patient diagnoses for risk adjustment. Accurate HCC coding at FQHCs ensures appropriate reimbursement for the complexity of patients served.

The principle that everyone should have a fair opportunity to achieve their full health potential regardless of race, income, geography, or social position. FQHCs are central to health equity because they serve communities facing the greatest barriers to care.

A set of standardized quality measures used to track healthcare performance in areas like diabetes control, preventive care, and medication use. FQHCs report HEDIS data to health plans.

The federal department overseeing health programs including Medicare, Medicaid, HRSA, and CMS. Sets national health policy affecting FQHCs.

A federal designation for areas with too few primary care, dental, or mental health providers relative to the population. Clinicians who work at an NHSC-approved site in a HPSA can apply for NHSC loan repayment. Medicare's separate 10 percent HPSA bonus applies only to a physician's professional services (42 CFR 414.67).

The federal agency within the U.S. Department of Health and Human Services that funds FQHCs through Section 330 grants and oversees their operations and reporting requirements.

A network of independent physicians and clinics that contract together with health plans to provide care and manage capitated risk. FQHCs sometimes partner with IPAs for capitated contracts.

A nonpartisan nonprofit organization producing health policy research and analysis. Known for Medicaid data, healthcare coverage tracking, and policy briefs.

Evidence-based treatment using medications like buprenorphine or methadone to treat opioid addiction. Many FQHCs provide MAT/MOUD services integrated with primary care.

California's Medicaid program that provides health coverage to low-income individuals and families. Medi-Cal is the largest payer for FQHC services in California.

A collaborative counseling technique that helps patients find their own motivation for behavior change. Widely used in FQHCs for smoking cessation, diabetes management, substance use treatment, and chronic disease self-management.

A geographic area with a shortage of healthcare services based on the ratio of providers to population, poverty rate, infant mortality, and elderly population. FQHCs must be located in or serve an MUA or MUP.

The national trade association representing FQHCs and community health centers. Advocates for FQHC funding, policy, and workforce issues at the federal level.

A federal loan repayment and scholarship program that helps clinicians pay off student loans in exchange for working at FQHCs and other under-resourced settings. Popular among physicians and nurses.

A shared Electronic Health Record system used by many California FQHCs. Allows for data sharing across organizations to improve care coordination and quality reporting.

A federal monitoring visit where HRSA staff inspect an FQHC's operations, financial management, clinical services, and compliance with Section 330 requirements.

An intermediary company that processes prescription drug claims between FQHCs, pharmacies, and health plans. PBMs negotiate drug prices and manage formularies.

A model of care where the FQHC coordinates all aspects of patient health—primary care, specialist referrals, mental health, and social services—with the patient's primary clinician leading the care team.

An approach that uses data to improve health outcomes for a defined group of patients. FQHCs use population health to identify high-risk patients, track chronic disease metrics, and allocate resources where they'll have the most impact.

A payment method that uses a defined formula rather than simply paying each billed cost. Medicare FQHC PPS uses a national base rate adjusted for location and certain visit types. Medicaid FQHC PPS is a separate statutory per-visit methodology based on a historical cost baseline with adjustments; qualifying alternative payment methodologies may also be used.

A Spanish-language term for Community Health Worker, especially common in Latino communities. Promotoras bridge cultural and language gaps between patients and clinics through health education, outreach, and advocacy.

A systematic approach to continuously improving patient care, safety, and operational efficiency. FQHCs use QI methodologies like PDSA cycles and Lean to improve UDS metrics, HEDIS scores, and patient satisfaction.

A payment methodology that adjusts reimbursement based on the health complexity of a patient population. FQHCs serving sicker patients receive higher payments. Accurate documentation and HCC coding drive risk-adjusted revenue.

Technology that allows FQHCs to track patient health data (blood pressure, glucose, weight) outside the clinic using connected devices. RPM generates billable visits and improves chronic disease management outcomes.

A billing metric that assigns points to medical services based on complexity and time. Each RVU has three components: physician work, practice expense, and malpractice. Under RVU-based payment, higher RVU services generate more revenue—can incentivize inappropriate coding.

A federal program providing funding to FQHCs and other providers for comprehensive HIV care, treatment, and support services. Covers patients without other insurance.

California law requiring FQHCs and other covered employers to pay healthcare workers at least $25 per hour by 2027. This affects FQHC payroll budgets significantly.

A public health approach for screening patients for substance use disorders during routine visits. FQHCs use SBIRT to identify at-risk patients early and connect them with treatment before problems escalate.

The legal boundaries defining what services a healthcare professional can provide based on their license, training, and state regulations. In FQHCs, working at 'top of scope' maximizes team productivity and revenue.

The non-medical factors that shape health outcomes—housing, food security, education, employment, and transportation. FQHCs screen for and address SDOH through CalAIM Community Supports and care coordination.

The federal statute that defines FQHCs and authorizes federal funding (grants) for community health centers. Requires FQHCs to serve all patients regardless of ability to pay and insurance status.

A payment model where patients pay fees based on their income and family size, from free to full cost. Required of all FQHCs to ensure affordability and access for low-income patients.

A medical condition involving the misuse of substances (drugs, alcohol) that causes significant functional impairment. FQHCs integrate SUD screening, treatment, and recovery support into primary care.

A Medi-Cal program (Welf. & Inst. Code §14132.44) in which local governmental agencies, such as counties and cities, claim federal reimbursement for case management for the target populations in the Medi-Cal State Plan. More targeted than ECM.

The delivery of healthcare services via video, phone, or messaging platforms. FQHCs expanded telehealth dramatically during COVID-19 and continue to use it for behavioral health, chronic disease follow-ups, and serving rural patients.

A clinical approach that recognizes the impact of trauma on patient health and behavior. FQHCs implement TIC by training staff to recognize trauma signs, avoid re-traumatization, and create safe healing environments.

A federal program funding family planning and reproductive health services at FQHCs and other clinics. Services include contraception, STI testing, and reproductive cancer screening. They are provided regardless of ability to pay, and low-income clients may pay nothing or pay on a sliding scale.

A federal data collection system where FQHCs report clinical, financial, and operational performance metrics to HRSA. Used to assess quality, access, and fiscal health.

Specific quality metrics FQHCs report annually to HRSA—including diabetes control (HbA1c <9%), hypertension control (<140/90), cervical cancer screening, and depression screening. Performance affects grant funding.

A reimbursement model that rewards providers for quality outcomes rather than volume of services. FQHCs are increasingly moving toward VBP through quality bonuses, shared savings, and capitation arrangements.

The additional payment FQHCs receive from Medicaid to make up the difference between the managed care plan's payment and the FQHC's PPS rate. Ensures FQHCs are reimbursed at their full cost-based rate.

The work component of an RVU: the clinician's time, skill, and effort in delivering a service. Practice expense and malpractice are the other two RVU components. Used by some clinicians to track productivity. Concerns exist about overuse incentivizing higher-complexity coding.