The Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care’s Scope of Project guidance has always been central to how Federally Qualified Health Centers (FQHCs) define, document, and operate their approved Health Center Program activities. With HRSA’s August 11, 2026, release of the Health Center Program Scope of Project Policy Manual, effective immediately, health centers now have a consolidated policy resource that addresses the core elements of scope: medically underserved populations and special medically underserved populations served, service area, services, sites, and providers.

For FQHCs, Scope of Project is the foundation for how a health center demonstrates that its services, sites, providers, and delivery arrangements are operating “on behalf of” the health center and within the HRSA-approved project. The Health Center Program Scope of Project Policy Manual states that health centers are responsible for conducting all activities within their approved scope of project and maintaining an accurate scope on appropriate HRSA forms and systems, including requesting prior approval for needed changes.

Why this matters for FQHCs

The money follows the scope; grant funds and every other dollar in a health center's HRSA-approved annual budget must be used for activities within the approved scope of project, and nothing else. Activities outside that scope are other lines of business, which cannot draw Health Center Program funding and do not carry the federal benefits tied to the program: FQHC Medicare and Medicaid payment rates, the 340B Drug Pricing Program, and the Health Center Federal Tort Claims Act (FTCA) Program.

The new Health Center Program Scope of Project Policy Manual consolidates prior scope-related policy into a single document and supersedes several prior Policy Information Notices, including guidance related to service area overlap, defining scope of project and requesting changes, specialty services, and special populations-only grantees requesting changes to add a new target population. This consolidation gives health centers an important opportunity to revisit whether their current operations, agreements, documentation, and HRSA forms accurately reflect how care is being delivered today.

The Manual also addresses several areas that are highly relevant to health center operations, including required and additional health services, service delivery methods, telehealth, service sites, other sites, co-located sites, contractor- or subrecipient-operated sites, temporary service sites, providers, patients, visits, and services provided at locations other than health center service sites. For many FQHCs, these areas touch day-to-day operations, referral relationships, contracts, board oversight, patient access, and compliance documentation.

Noncompliance carries its own consequences. The Manual says HRSA may correct, modify, disapprove, or remove sites, services, or activities from an approved scope, require repayment of federal funds not used consistent with that scope, and withhold future funding.

Preparing for what comes next

Health centers should not assume that existing operations are automatically aligned with the new Health Center Program Scope of Project Policy Manual. The new Manual should prompt every FQHC to pause and ask: Does our approved scope match what we are actually doing today?

Current practices may have evolved over time through new partnerships, expanded service lines, telehealth models, mobile or temporary sites, referral arrangements, co-located services, or contractor-supported delivery models. Each of these activities should be reviewed against HRSA’s updated policy expectations and the health center’s approved scope documentation.

A systematic and practical review can help identify whether the health center’s approved scope accurately reflects current operations, whether documentation supports compliance, and whether any operational changes may require HRSA review or approval. It can also help leadership and the board better understand where policy, procedure, agreement language, and actual practice may need to be updated.

How CohnReznick can help

By acting now, health centers can strengthen compliance, reduce uncertainty, and better prepare for change-in-scope planning, operational reviews, and future HRSA interactions. Health centers will begin seeing the impact of the new Scope Manual in November 2026, when the Change in Scope system reopens to reflect anticipated revisions, followed by updated Operational Site Visit Protocols in 2027 to align with the Scope of Project Policy Manual.

CohnReznick helps FQHCs translate the new Health Center Program Scope of Project Policy Manual into actionable guidance, clear recommendations, and a practical roadmap for alignment.

Through a focused scope of project assessment, CohnReznick can compare current operations and operating models against FQHC requirements, the Health Center Program Scope of Project Policy Manual, the Health Center Program Compliance Manual, and the organization’s Forms 5A and 5B. The review may include scope training, assessment of services and sites, review of policies and procedures, identification of priority gaps, and development of practical workplans to achieve compliance.

CohnReznick’s approach can include:

• • Reviewing current sites, services, providers, service area, and medically underserved/special population designations against HRSA-approved scope documentation
  • Assessing Form 5A service delivery methods, including direct services, formal written contracts/agreements, and referral arrangements
  • Reviewing Form 5B site information and helping identify whether current locations align with HRSA’s site criteria
  • Evaluating whether policies, procedures, contracts, and referral arrangements match how the center actually operates and what HRSA expects
  • Developing a gap assessment and action-oriented workplan to help leadership and the governing board prioritize updates.