Form 32 Checklist for Deleting Existing Service - track changes.

OMB No.: 0915-0285. Expiration Date: xx/xx/xxxx

Checklist for Deleting Existing Service

Assurances:

• I certify that the following statements related to the preparation of this Change in Scope (CIS) request are true, complete and accurate:

• This CIS request is complete and responsive to all applicable criteria relating to the CIS checklist. Refer to http://www.bphc.hrsa.gov/programrequirements/scope.html for all applicable policies and guidance.

• The health center consulted with its Project Officer prior to submitting this CIS request.

• The proposed CIS implementation date is at least 60 days from the submission date to HRSA. Note: HRSA recognizes that there may be circumstances where submitting a CIS request at least 60 days in advance of the desired implementation date may not be possible; however, the goal is to minimize these occurrences through careful planning. Refer to http://www.bphc.hrsa.gov/policiesregulations/policies/pdfs/pal201410.pdf)

• The health center’s governing board approved this CIS request prior to submission to HRSA, as documented in board minutes (must be made available upon request).

• The health center has examined the potential impact of this CIS under the requirements of other programs as applicable (e.g., 340B Program, FTCA).

• The health center understands that HRSA will consider its current compliance with Health Center Program requirements and regulations (i.e., the status and number of any progressive action conditions) when making a decision on this CIS request. (See PAL: 2014-08 Health Center Program Requirements Oversight for more information on progressive action).

• I will ensure the health center complies with the following statements related to the implementation of this Change in Scope (CIS) request, if approved:

• All Health Center Program requirements (http://www.bphc.hrsa.gov/programrequirements/index.html) will apply to this CIS. Note: Compliance with Health Center Program requirements across sites and services will be assessed through all appropriate means, including site visits and application reviews.

• This CIS will be undertaken directly by or on behalf of the health center for the benefit of the current or proposed health center patient population, and the health center’s governing board will retain oversight over the provision of any services and/or sites.

• This CIS will be accomplished without additional Health Center Program Federal award funding and will not shift resources away from carrying out the current HRSA-approved scope of project.

• The impact of this CIS will be reflected in the total budget submitted with the health center’s next annual competing or non-competing or designation application.

• This CIS will be implemented and verified within 120 days of receiving the NoA or HRSA notification approving the change. Refer to http://www.bphc.hrsa.gov/policiesregulations/policies/pdfs/pal201410.pdf.

• This CIS will not diminish the patient population’s access to and quality of services currently provided by the health center.

• No additional changes in scope are necessary to implement this CIS (e.g., approval of a new site does not entail approval of any new services to be provided at the new site).

• The health center will take all applicable steps related to the requirements of other programs impacted by this change in scope request.

Change in Scope Questions:

Is this request to delete a service linked to another recently submitted, in progress or planned CIS request (e.g., the health center will be deleting a site at which this service is provided)?

Y/N – require text box explanation if Y

1. OVERVIEW:

FOR ADDITIONAL/SPECIALTY DELETION ONLY: Provide a brief background/justification for why the health center is proposing to delete the service from its scope of project (e.g., major decrease in demand for service based on shifting target population health needs, improve capacity by providing service via formal referral vs. directly).

FOR REQUIRED SERVICES TO COLUMN III ONLY: Provide brief background/justification for why the health center is proposing to provide this service only through a Formal Written Referral Arrangement(s) (Form 5A, Column III) where the actual service is provided and paid/billed for by another entity (e.g., major decrease in demand for service based on shifting target population health needs, improve capacity by providing service via formal referral vs. directly).

Requires narrative response.

Proposed Date of Service Deletion: mm/dd/yyyy

Note: Please review Program Assistance Letter 2014-10: Updated Process for Change in Scope Submission, Review and Approval Timelines and Policy Information Notice 2008-01: Defining Scope of Project and Policy for Requesting Changes. In cases where a health center is not able to determine the exact date by which a CIS will be fully accomplished, BPHC will allow up to 120 days following the date of the CIS approval Notice of Award (NoA) or look-alike Notice of Look-Alike Designation (NLD) for the health center to implement the change (e.g., stop providing the service). Review Program Assistance Letter 2009-11: New Scope Verification Process for more information.

2. MAINTENANCE OF LEVEL AND QUALITY OF HEALTH SERVICES: Describe how the health center intends to maintain, to the extent possible, the level and quality of health services currently provided to the patient population by discussing:

1. The impact of deleting the services on the total number and percent of patients across service types (medical, dental, etc.);

2. how deletion of the service may impact access to and/or level of demand for health center services in the current approved scope of project (Required and Additional Services as reflected on the health center’s Form 5A) (e.g., if the health center is proposing to stop providing additional dental services, if and how will this impact the demand for preventive dental services);

3. the average travel time and distance for patients to closest other location(s) to receive the service if this service is deleted from scope;

4. any new or enhanced transportation or enabling services to support access the service at referral or other provider sites or locations; and

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

6. FOR REQUIRED SERVICE ONLY: how data will be obtained from referral provider(s) for UDS reporting purposes

Requires narrative response.

3. FOR ADDITIONAL/SPECIALTY DELETION ONLY: Outreach AND COMMUNICATION:

1. Describe how the health center will communicate with current health center patients and the community at large (e.g., other Health Center Program grantees and Look-alikes, rural health clinics, critical access hospitals, health departments, etc.), to raise awareness that the service will no longer be provided by the health center.

2. If the service will be removed from scope entirely (i.e., the health center will not provide a formal referral for the service), discuss how (1) the health center will make patients aware of other community providers or organizations that offer the service; and (2) the health center's policies and procedures ensure continuity of care for current patients that may seek this service through other community providers.

3. If the service will be removed from scope but provided via a formal written referral arrangement, discuss how the health center will make patients aware that the service available via referral.

Requires narrative response.

4. Attach any documents relevant to the service deletion that demonstrate the health center’s outreach and communications (e.g. sample patient notification documents, local media announcements about site deletion, new MOUs, etc.).

Mandatory attachment that supports response

4. FOR REQUIRED SERVICES TO COLUMN III ONLY: REFERRAL ARRANGEMENT DETAILS:

The proposed service will be provided via a Formal Written Referral Arrangement (where the actual service is provided and paid/billed for by another entity (the referral provider) and thus the service itself is NOT included in the health center's scope of project (Note: 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). Therefore, describe:

1. How the referral arrangement is documented (i.e., via an MOU, MOA, or other formal agreement);

2. How the referral arrangement addresses the manner by which the referral will be made and managed; and

3. How the referral arrangement addresses the tracking and referral of patients back to the health center for appropriate follow-up care.

Requires narrative response

No attachment requested/required

5. FUNDED SERVICE: Was the service to be deleted added to scope through a HRSA-funded application (e.g., New Access Point, Service Expansion)? If yes, address how the health center plans to achieve/maintain the patient projections included in the original application for the service. Note: health centers are expected to comply with terms and conditions of all awards, including serving the number of patients that have been served in the service area plus those the health center has committed to serve through recently-awarded HRSA funding.

Yes/No radio button; require narrative if Yes

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0285. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857.

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)

2a.	PROPOSED DATE OF SERVICE DELETION

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

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)

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)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

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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)

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)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

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?

Yes

No

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


List Page #(s):

Available equally to all health center patients?

Yes

No

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


List Page #(s):

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?

Yes

No

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


List Page #(s):

Attach the referral arrangement(s) documentation (draft documents are acceptable) here.

Referral Arrangement (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

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.

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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)

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)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

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)

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)

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?

Yes, but a separate CIS to remove these site(s) from scope will be submitted. No

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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.

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

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?

Yes	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)

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?

Yes

N/A

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

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