* 1. Your Health Center Information:

* 2. Does your vision service provide on-site comprehensive vision and eye health care including refractions, dilated eye examinations, and treatment and monitoring of diseases such as glaucoma?

* 3. How many full-time optometrists are employed? (employed more than/equal to 32 hours per week)

How many part-time optometrists are employed? (employed less than 32 hours per week)

*Full-time employees are calculated as 1.0, part-time employees are calculated as 0.5.

* 4. How many full-time/part-time optometric assistants are employed?

How many full-time/part-time ophthalmologists are employed?

*Full-time employees are calculated as 1.0, part-time employees are calculated as 0.5.

* 5. Does your vision service offer on-site optical services/eyeglass for ordering and dispensing?

* 6. Does your vision service limit care to only certain patients or age groups?

* 7. Payment methodologies for FQHCs and FQHC Look-Alikes are designed to fully account for the true and complete costs of delivering the range of FQHC services provided. State Medicaid Agencies reimburse FQHCs under a prospective payment system (PPS) or an equivalent alternative payment methodology (APM). These regulated payment methodologies adjust reimbursement upward for FQHC services under certain circumstances.

Question: Does your health center receive the PPS or APM rate for an eye care visit?

* 8. Payment methodologies for FQHCs and FQHC Look-Alikes are designed to encourage participation with Managed Care Organizations (MCO’s). When payments received by MCO’s are less than the PPS or APM per-visit rate, the State Medicaid Office reimburses the FQHC the difference. This difference is known as the “wraparound payment”.

Question: Does your health center receive the “wraparound payment” for an eye care visit paid for by a MCO?

* 9. Can you provide CFO contact?

* 10. Additional comments:

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