Form 1 Checklist for deleting existing service

The Health Center Program Application Forms

21. Checklist for Deleting Existing Service

Checklist for Deleting Existing Service

OMB: 0915-0285

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CIS Editable Checklist – Grantee Checklist – Delete Service

Change Checklist






DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

CHECKLIST FOR DELETING A SERVICE (CHKLST002)

Grantee Name:

Grantee Number:

CIS Tracking Number:





Questions for Deletion of Service


In this CIS request, you have marked the following service for deletion:




Date Service Proposed for Deletion was Added to Scope:




1.

BACKGROUND AND JUSTIFICATION FOR SERVICE DELETION

Provide brief background/justification for why your health center is proposing to remove this service from your scope of project (e.g. major decrease in demand for podiatry services based on shifting target population health needs, financial recovery plan, improve capacity by providing service via formal referral vs. directly etc.).

If the service to be deleted was added to scope through a HRSA-funded application (e.g. New Access Point or Service Expansion), the health center MUST state this and must specifically address if and how the patient and visit projections included in the approved application that originally added the service to scope will be maintained.







Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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2a.

PROPOSED DATE OF SERVICE DELETION






When will you stop providing the service? (mm/dd/yyyy) : Shape2





2b.

OUTREACH AND COMMUNICATION PLAN

Describe outreach and communication plans for informing current health center patients and the community at large that this service will no longer be provided by your health center. Address all of the applicable bullets below in your response.

  • If the service will be removed from scope entirely (i.e. the health center will not provide a formal referral for the service), discuss any plans for making patients aware of other community providers or organization that offer the service.

  • If the service will be removed from scope but provided via a formal written referral arrangement, discuss plans for making patients aware that the service is still available via referral.

  • Discuss any new or enhanced transportation or enabling services available to access this service at referral or other community provider sites or locations.






Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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Optional: Upload any attachments relevant to the service deletion here that support the health center’s communication and outreach plans (e.g. sample patient notification documents, local media announcements about service deletion, etc.).




Outreach and Communication Supporting Documentation (Maximum 6 attachments)

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Purpose

Document Name

Size

Uploaded By

Description

No attached document exists.

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Click "Save" button to save all information within this page.

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3.

ONLY APPLICABLE FOR ADDITIONAL SERVICES THAT WILL BE REMOVED FROM SCOPE ENTIRELY

MAINTENANCE OF LEVEL AND QUALITY OF HEALTH SERVICES

Clearly describe in a brief narrative format, the health center's plan for assuring that the deletion of this service will in no way result in the diminution of the health center's total level or quality of health services currently provided to the patient/target population of the health center. Address ALL of the following:

  • What is the number of patients that will be affected by the deletion of the service and/or how will this impact overall health center (medical, dental, etc.) visit numbers? What proportion of annual patient visits does this represent?

  • Describe if and how deletion of this service will impact access to and/or level of demand for any other Required or Additional health center services in the current approved (as reflected on the health center's Form 5A) scope of project (e.g. if the health center is proposing to stop providing restorative dental, if and how will this impact the demand for preventive dental services?).

  • Describe how the health center will address any other barriers to care that the deletion of the service may present.

  • Describe your health center's policies and procedures for ensuring continuity of care for current patients that may seek this service through other community providers that the health center may not have a formal referral relationship with (e.g. if patients will receive podiatry services through the local VA, will the health center provider make efforts to obtain follow up results of these visits within the patient's primary care record?).






Maximum page(s) allowed approximately: 2 (5000 character(s) remaining)
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Optional: Upload any attachments relevant to the service deletion that support the health center's assurance that the total level or quality of health services currently provided will be maintained (e.g. maps, transportation plans, etc.).






Maintenance of Quality & Level of Health Services Supporting Documentation (Maximum 6 attachments)

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Purpose

Document Name

Size

Uploaded By

Description

No attached document exists.

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4.

FORMAL WRITTEN REFERRAL ARRANGEMENT(S)

If the service to be deleted will now be provided ONLY via a Formal Written Referral Arrangement(s) (Form 5A, Column III) where the actual service is provided and paid/billed for by another entity (the referral provider) and thus the service itself will NO LONGER be included in the health center's scope of project but the establishment of the actual referral arrangement and any follow-up care provided by the health center subsequent to the referral are included in scope –respond to all of the following.





4a.

Is the referred service:

Documented via an MOU, MOA, or other formal agreement(s) that at a minimum describes the manner by which the referral will be made and managed, and the process for tracking and referring patients back to the health center for appropriate follow-up care?








Shape8 Yes

Shape9 No


Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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List Page #(s):
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Available equally to all health center patients?








Shape12 Yes

Shape13 No


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List Page #(s):
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Available regardless of ability to pay by assuring that the referral provider(s) offers a sliding fee discount program (sliding fee discount schedule, including any nominal fees and related implementing policies and procedures) for the referred service to patients with incomes at or below 200 percent of the Federal Poverty Guidelines?









Shape16 Yes

Shape17 No


Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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List Page #(s):
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Attach the referral arrangement(s) documentation (draft documents are acceptable) here.




Referral Arrangement (Maximum 6 attachments)

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Purpose

Document Name

Size

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Description

No attached document exists.

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It is the responsibility of the health center to ensure that the arrangement does NOT inappropriately imply the conference of the benefits and/or privileges of Health Center Program grantees or Look-Alikes such as 340B Drug Pricing or FQHC reimbursement, on the other party.





Click "Save" button to save all information within this page.

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4b.

Describe enhanced and/or increased transportation or other relevant enabling services that will be available to assist patients in accessing this referred health center service, and how the health center will address any other possible access barriers at the referral provider’s site/location?






Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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5.

FINANCIAL IMPACT ANALYSIS







Template Name

Template Description

Action

Financial Impact Analysis

Template for Financial Impact Analysis

Instructions

Instructions for Financial Impact Analysis









Attach Financial Impact Analysis Document here.




Financial Impact Analysis (Maximum 6 attachments)

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Purpose

Document Name

Size

Uploaded By

Description

No attached document exists.

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Explain how adequate revenue will continue to be generated to cover existing expenses across the overall scope of project incurred by the health center. If the overall scope and total budget of the health center will be reduced as a result of the service deletion (including any reductions in staffing), specify this. The Financial Impact Analysis must at minimum show a break-even scenario or the potential for generating additional revenue.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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6.

HEALTH CENTER STATUS

Discuss any major changes in the health center's staffing, financial position, governance, and/or other operational areas, as well as any unresolved areas of non-compliance with Program Requirements (e.g. active Progressive Action conditions) in the past 12 months that might impact the health center’s ability to implement the proposed change in scope.






Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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7.

SITES

Will this service deletion result in the deletion of any
sites currently included within the approved scope of project as documented on your health center’s Form 5B?






Shape26 Yes, but a separate CIS to remove these site(s) from scope will be submitted.

Shape27 No







Click "Save" button to save all information within this page.

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Additional Considerations for Deleting a Service from Scope

While the following areas are not specific factors or criteria that will impact the CIS approval process, these are key elements that health centers should have considered or actively planned to address prior to deleting a service from the scope of project.







A.

Medical Malpractice Coverage:

For grantees deemed under the Federal Tort Claims Act (FTCA), be aware that FTCA coverage is limited to the performance of medical, surgical, dental, or related functions within the scope of the approved Federal section 330 grant project, which includes sites, services, and other activities or locations, as defined in the covered entity's grant application and any subsequently approved change in scope requests.

Confirm that your health center is aware that if the request to delete this service is approved, FTCA coverage will no longer extend to any activities, providers, etc. associated with the deleted service as of the date of the approval to remove the service from scope.






Shape29 Yes, health center is aware that removing this service from scope will result in the loss of FTCA coverage for the deleted service.

Shape30 N/A, health center is not deemed or FTCA coverage does not apply.

For more information, the FTCA Health Center Policy Manual is available at:http://www.bphc.hrsa.gov/policiesregulations/policies/pin201101.html For specific questions, contact the BPHC HelpLine at: 1-877-974-BPHC (2742) or Email: [email protected]. Available Monday to Friday (excluding Federal holidays), from 8:30 AM - 5:30 PM (ET), with extra hours available during high volume periods.

Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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B.

Section 340B Drug Pricing Program Participation: Health centers that participate in the 340B Drug Pricing Program are reminded that changes to the scope of project approved by BPHC do not automatically update within the 340B Program’s Database. Health centers should contact the HRSA Office of Pharmacy Affairs to determine whether any updates to the 340B Database are necessary by contacting Apexus Answers at 888-340-2787, or [email protected].

Will your health center complete all necessary 340B Program updates with the HRSA Office of Pharmacy Affairs?






Shape32 Yes

Shape33 N/A, health center does not participate in the 340B program






Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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C.

Reimbursement as a Federally Qualified Health Center (FQHC) under Medicare, Medicaid and CHIP:

The Medicaid statute and program guidance require that an FQHC's Medicaid reimbursement rate be adjusted to reflect changes in the "type, intensity, duration, and/or amount of services" provided. Therefore, a HRSA-approved change in the services covered under a health center's scope of project may necessitate a change in the health center's FQHC Medicaid reimbursement rate. In these situations, it is the responsibility of the health center to notify its State Medicaid Agency of the change(s) in services following HRSA approval. For further information about the process for adjusting rates based on changes in services provided, health centers should contact their Primary Care Association or State Medicaid Agency.

After HRSA approval of the change in scope, will your health center notify the State Medicaid Agency of any changes to services covered under the HRSA scope of project that may affect your center's Medicaid reimbursement rate?






Shape35 Yes

Shape36 N/A






Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorEshita Shaheed
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File Created2021-01-28

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