POLICY INFORMATION NOTICE DOCUMENT NUMBER: 2009-04

DATE: January 14, 2009 DOCUMENT TITLE: Revision to Policy Information Notice 2003-21: Federally Qualified Health Center Look-Alike Guidelines and Application

TO: Federally Qualified Health Center Look-Alikes Health Center Program Grantees Primary Care Associations Primary Care Organizations National Cooperative Agreements

This Policy Information Notice (PIN) announces a revision to PIN 2003-21: Federally Qualified Health Center (FQHC) Look-Alike Application and Guidelines. Effective immediately. the Office of Management and Budget (OMB) approval for inIonnatio" collection, control number 0915-0142, has been extended to November 30, 2011.

This OMS approval provides the Health Resources and Services Administration (HRSA) with the authority to continue to collect the data specified in PIN 2003-2 1 in order to make a determination on an organization's compliance with FQHC Look-Alike requirements. Note the following changes in data submission requirements have been made to PrN 2003-21 :

• Race and ethnicity data is now collected as two separate data elements in Table 2, Part S, to meet OMS Standards for the Classification of Federal Data on Race and Ethnicity as well as Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity (62 Federal Register (FR) 36874-36946; 62 FR 58781 -9; and OMB Bulletin #00-02).

FQHC Look-Alikes and applicants must use the attached tables in addition to the guidelines in PIN 2003-2 J when making submissions. Please note that all infonnation provided regarding race and/or ethnicity will be used only to ensure compliance with statutory and regulatory Governing Board requirements set forth in section 330 of the Public Health Service Act. Data on race and/or ethnicity collected on this fonn will not be used as a factor in recommending approval for FQHC Look-Alike designation, recertification. or change in scope of project.

To access PIN 2003-21 and other relevant documents (e.g., PINs 2005-17 and 2006-06, and Program Assistance Letters 2006-01, and 2008-07), please visit HRSA's Web site at: http://bphc.hrsa.gov/policv/#lookalikes.

Policy Infonnation Notice 2009-04

If you have any questions regarding this PIN or the FQHC Look-Alike Program, please contact the Office of Policy and Pr ent at 301-594-4300.

James Macrae Associate Administrator

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OMB Number: 0915-0142; Expiration Dale 11 /3012011 Policy Infor maljon Notice 2009·04

TABLE I - SERVICES OFFERED AND DELIVERY METHOD

&""1<'" T)'pt

I'ro.idtd by Si't

M

8y Rdt ...... 1 orCon.nt. Si ' t Pa~~'

(')

8y Mdt . ... 1 No. orCon.nt. fn~i dtd

No " ym. I< (,)

S"''''ct Tn'"

froo·'cltd by Si.~

(0)

Dy Rdt ..-ra l orC .... nt. Sirt f.)" •

(»

By Rdcrn l ...C ..... .-.d

N .. I»· ... 1<)

1'0 ... f ... ~,dtd

I')

\leohal Co", Mni<:rt. Mr<ltlIi IIt.hlll S.bs, ... u AbllK ~rvN:C$

I.) Gmrnl Pnmary Medical Care (JI/oc>r.~ "Iv",) 25.) Meollal H""l!h Truuncnr.IC_ling

2.) Oi.to"","ic UboraIory (In:lutIC<lI~) 26.) De>T1op_IlUO' ~'ng

3.) l)jag:DO$l.lC X·RAy (ledlnlCtJl ~Itl) 27) 24-hoor Cru,s I .... ~n"o .. lCounsel'"'

4.) DlagnOSlle TcsulSc:fftfI"'p (profn:uonoI crMIp.) 28.) 0Ihcr t>imC.al Heal'" ServlCCS

5.) Erne~ Medoc:al ServICeS 19.) Subslanc:c Abuse T'9IlIlCncICoun""hnl

6.) Ur~nI Medicil Carc llJ.) 0Ibcr SubsUonec: Abuse ScrvIct.$

1) 24-hour COvtlllgc Oilier f",r~II.1 ~n·1t1'5

3) Fam ily Ma nning 3 I ,) HearinM !k.ctnin,l

9) HI'll Testing 32,) N..ui.ion Services OIher.1tan WIC

10.) Immun,Ulions 33.) <kcup;IhONI or Vocational Therapy

II.) FoIlowlll! 1I0000w,;(Cd PallCnlll 34.) PhYSlCal"T"lomlpy

35.) PIwm""y

o.'Clrical .. d Gy....colocica' Cert' 36.) Vision Sa=una

12.) Gync<:o!otllC,l Care 37) WlCScnoICC:l

n.) ,,",..aul Cue OtMrStn·Ous

14.) Antepartum Fe.al Aness ... e", 38.) Case Manasernent

15.) Ultnllsound 39.) Child Carc (d,mng vUlI M SI,t)

16 ) Genthe Counselons and TmillS 40 .) Discha'~Plannjnl

17.) Am~io«nlcsl! 4 1.) Eligibility Assist~ra

13.) labor and Del,very Professional ~ 42.) EmpIoymentl'Ed_'lOIIal CowI5clillt

19.) Pos.partum C.C 43.) Environmcnul Hllh RISk Rodel1l (016 ()rl""",)

44) Food BaIlk /Ikh.-ered Meals

Stlc'ciall) MfdJaoI U,.., 45) Heohh EducaTion

20.) Dorectl) 0bser0"Cd Tll"T1ocnpy 46.) HOIlS'"' ,,",Stance

2] ) OI"'rSp:c,akyCar~ 47.) lntaprt •• ionf("ransiallOll ServIces

48) NUBi"g Home &: Assl51cd I.lving J>lacCIlICII.

OtoaUol C.rt' !M-,..kelo 49 .) Outre""h

21 ) 01/ .... 1 c.~ Pn:vt'nll\~ 50.) Tnlll.portalloo

23) Delila! Care - RcSiODl i.-e S I.) Home V;Sll1nil

24) Demal Care - Emct,ency 52.) ?wenhn, Ed .. ~tion

53 ) Odwr (s!,«try )

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OMB Number: 0915-0142; Expirat ion Date 11/30120 11 Policy In rormation Notice 2009-04

TABLE 2 - PATIE NTS

TABLE 2- PART A

PATIENTS BY AGE AND GENDER

Age Groups Male: Female Prenatal Patients Patients I'alients

1.) Under age I

2.) Agcs 1-4

J.) Ages S-12

4.) Ages 13-14

S.) Ages lS-19

6.) Ages 20-24

7.) Ages 2S-44

8.) Agcs 4S-6<\

9.) Ages 65-74

10.) Ages 75-&4

II.) Ages 85 and over

12.) Total Pmienl5

TABLE 2 - PART B PATIENTS BY ETHNICITY

Ethniciry Number of Patients

Number in Service Area

I.) Hispanic or Latino

2.) Unn:porIediUnknown

J.) Tow Patients

TABLE 2 - PART B PATIENTS BY RACE

Racc/lLanguage Numbero( PatientS

Number in Service Area

1.) Niian

2.)

3.)

American Indian or Alaska Native

Black or African American

4.) Native Hawaiian or Olhc:r Pacific Islander

s.) WhIle

7.) UnreponediUnkno\\TI

8.) Totol PalicnlS

9.) Patients Needin& Interpretation Services

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OMS Number: 0915·0142; Expiration Date 11/3012011 Policy Information Notice 2009·04

TABLE 2 - PART C PATIENTS BY INCOME LEVELS

Pcrccnt of Poverty Lc"cI Nlimberof Paticnts

NlIm\)(r in ~rvicc Area

I.) 100% and below

2.) 101 - 200%

3.) Abo,·c 200%

4.) UnrcponedlUnknown

S.) Total Pmicnts

TABLE 2 - PART D

PATIENTS BY PAYMENT SOURCE PaymCnL Sources Number of PcrccnL of Patients

Patients

1 ) Medicare

2.) Medicaid

J ) Othcr Public Insurance

4.) Other Third Parties

5.) Self-Pay

6.) TOial Patients 100%

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OMS Number: 0915-0142 ; Expiration Date 11 130120 11 Policy Information Notice 2009·04

TABLE 3 - PROVIDERS

Tolal SlalU! Slaif HO'pil,1 Board Tol,' Lknn Ad",illi", Certified [llcounter IT" (P'ace ~X " ir

PenotlllfJ by ~bJor Sen'lce Ca 1rt0ries (Vf.'\i) (VIN) [mploytd diffi'lly; Pri"iI~OlI • ~C' if by """'riC') (YIN)

Medical Prm iders (I c .. General I'TIIC'UUonCfS. InterniSts. Ob$ltUIClaniGynccoioglsts. PahaulcWIS, Other PIl)"1icl!lll Speclllis15, NulSC I'rIctmoners. Ccnlfied NulW MId,WI'cs)

Dental Pro\'id ers (I e. Dentists, l)enUlIII)'8icnlsts)

Mental Health & Substance Abuse Providers (i c, PS}duaLnsts. OIJscor speclallsu)

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OMB Number: 09\5 -0142; Expiration Date 11 /30/20 11 Policy Infonnation Notice 2009-04

TABLE 4 - PATIENT SERVICE CHARGES, COLLECTIONS, AND SELF-PAY ADJUSTMENTS

Payment Source Full Charges Amount Co llected

Adjustments

AI(!(licare

I .} Medicare Fee-for-Service

2.} Medicare Capitated

3.) Total Medicare (Lines 1 and 2)

Medicaid

4.) Medicaid Fee-for-Service

5.) Medicaid Cap itated

6.) Total Medicaid (Lines 4 and 5)

Other Public Payers

7.) Other Public Fee-for-Service

8.) Other Public Capitated

9.) Total Other Public (Lines 7 and 8)

Other 111ird Part)'

10.) Other Third Party Fee-for-Service

II .) Other Third Party Capitattd

12.) Total Other Third Party (Lines 10 and J I)

Self-Pay

13.) Self-Pay

14.) Total (Lines 3, 6,9,12, alld 13)

Self-Pay Adjustment Type

15.) Self-Pay Sliding Fee Adjustments

16.) Other Self-Pay Adjustments (Self-Pay Bad Debt and Chari ty Care)

17.) Total Self-Pay Adjustments (Lines / j and /6)

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OMB Number: 0915-0142; Expiration Date 11 /3012011 Policy Information Notice 2009-04

TABLE 5 - CURRENT BOARD MEMBER CHARACTERISTICS

Total Number/Range of Members Established in By-Laws or Articles of Incorporation: Positions Filled: __ _ as o f_~/_~/ __

Name Board Office Held

Patient Status (YIN)

Area of Expertise

Live (L) or Work (W) in Serv ice

Area

Years of Continued

Board Service

I.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Indicate # Board Members by Sex: F ~ -,--_ _ _ M~ ---Indicate # Board Members by RacelEthnicity:

White: -,-___ .,-_ Hispanic or Latino: _ __ _

Black/African American: --:-:--c:----- AsianlPacific Islander: _ ___ _ American Indian & Alaska Native: _ __ _

Notes: - Use additional pages if necessary. - lfboard member is not a Patient (i,e. , "N" in column 3) indicate if that member derives

more than 1 0% of hislher income from the health care industry (e.g. , "N > 1 0%" or "N < 1 0%").

- Migrant/Seasonal Farmworkers should be noted under Area of Expertise, and should reflect a reasonable proportion to their share of the Patient population.

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