Questions
for Deletion of Service
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In
this CIS request, you have marked the following service
for deletion:
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Date
Service Proposed for Deletion was Added to Scope:
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1.
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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.
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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2a.
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PROPOSED
DATE OF SERVICE DELETION
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When
will you stop providing the service? (mm/dd/yyyy) :
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2b.
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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.
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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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Select
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Purpose
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Document
Name
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Size
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Uploaded
By
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Description
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No
attached document exists.
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Click
"Save" button to save all information within
this page.
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3.
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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?).
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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
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Document
Name
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Size
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Uploaded
By
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Description
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No
attached document exists.
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4.
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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.
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4a.
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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?
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Yes
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No
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
List
Page #(s):
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Available
equally to all health center patients?
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Yes
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No
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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?
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Yes
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No
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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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Select
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Purpose
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Document
Name
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Size
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Uploaded
By
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Description
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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.
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Click
"Save" button to save all information within
this page.
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4b.
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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?
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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5.
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FINANCIAL
IMPACT ANALYSIS
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Template
Name
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Template
Description
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Action
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Financial
Impact Analysis
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Template
for Financial Impact Analysis
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Instructions
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Instructions
for Financial Impact Analysis
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Attach
Financial Impact Analysis Document here.
Financial
Impact Analysis (Maximum 6 attachments)
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Select
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Purpose
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Document
Name
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Size
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Uploaded
By
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Description
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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.
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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.
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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7.
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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?
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Yes,
but a separate CIS to remove these site(s) from
scope will be submitted.
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No
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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.
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A.
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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.
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Yes,
health center is aware that removing this service
from scope will result in the loss of FTCA coverage
for the deleted service.
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N/A,
health center is not deemed or FTCA coverage does
not apply.
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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: bphchelpline@hrsa.gov.
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.
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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 ApexusAnswers@340bpvp.com.
Will
your health center complete all necessary 340B Program
updates with the HRSA Office of Pharmacy Affairs?
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Yes
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N/A,
health center does not participate in the 340B
program
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Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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C.
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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?
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Yes
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N/A
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Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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