Essential

ESSENTIAL HOSPITAL DESIGNATION TABLE

Please complete this form with the indicated information about each hospital that applicant seeks to have designated as essential. Please note that, under Section 1858(h) of the Social Security Act (the Act) and 42 CFR 422.112(c)(3), applicant organization must have made a good faith effort to contract with each hospital that it seeks to have designated as essential. A “good faith” effort is defined as having offered the hospital a contract providing for payment rates in amounts no less than the amount the hospital would have received had payment been made under section 1886(d) of the Act. The attestation on the following page must be completed and submitted with the completed chart.

Hospital name and address (including county)	Contact person and phone	Hospital Type/Provider Number	Method by which offer was communicated	Date(s) offer refused/how refused	Why hospital is needed to meet RPPO’s previously submitted access standards, including distance from named hospital to next closest Medicare participating contracted hospital
Happy Care Medical Center 211 Green St., Foxdale, Delaware County, PA 21135	Any Body, CFO (215) 345-1121	Acute Care/ 210076	2 Letter Offers followed by 2 phone calls	Letter dated 8/02/05. Confirmed by phone call with CFO	Nearest Medicare participating inpatient facility with which applicant contracts is in downtown Philadelphia, PA – 35 or more miles away from beneficiaries in Delaware County. Applicant’s hospital access standard is 98% of beneficiaries in Delaware County and northern half of Chester County have access to inpatient facility within 30 miles drive.

Regional Preferred Provider Organization (RPPO) Attestation Regarding Designation of “Essential” Hospitals

Applicant Organization named below (the Organization) attests that it made a good faith effort consistent with Section 1858(h) of the Social Security Act (the Act) and 42 CFR 422.112(c)(3), to contract with each hospital identified by the Organization in the attached chart at rates no less than current Medicare inpatient fee-for-service amounts and that, in each case, the hospital refused to enter into a contract with the Organization.

CMS is authorized to inspect any and all books or records necessary to substantiate the information in this attestation and the corresponding designation requests.

The Organization agrees to notify CMS immediately upon becoming aware of any occurrence or circumstance that would make this attestation inaccurate with respect to any of the designated hospitals. I possess the requisite authority to execute this attestation on behalf of the Organization.

Name of Organization: ______________________________________________

Printed Name of CEO: ______________________________________________

Signature:_________________________________________________________

Medicare Advantage RPPO Application/Contract Number(s):

R#_____ ______ ______ ______ ______ ______ ______ ______ ______ ______

NOTE: This attestation form must be signed by any organization that seeks to designate one or more hospitals as “essential.”

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Medicare Advantage Regional PPO Application, 1/21/05