Starting a Rural Health Clinic - A How-To Manual

Chapter Four - Filing the RHC Application

A practice is eligible for initial RHC certification if it is located in an area "currently" designated as a Medically Underserved Area (MUA) or Health Professional Shortage Area (HPSA) - either population or geographic. In addition, Governors are authorized to designate areas with a shortage of personal health services for purposes of obtaining RHC status. In order for a shortage area designation to be considered "current" it cannot be more than 3 years old. Once you have determined that the site is eligible for RHC designation and you have completed the Financial Feasibility Analysis, you are ready to file the RHC application.

The RHC application is broken into two parts:

• the RHC application; and,
• the CMS 855A Provider/Supplier Enrollment application

You can obtain an RHC application packet from the State agency responsible for administering the RHC program for CMS in the State in which the clinic is located. Appendix A lists the State agency for each State. The RHC application packet should include the following items although the numbers of the forms may have changed so check with CMS to ensure proper compliance:

• CMS-29 Request to Establish Eligibility to Participate in the Health Insurance for the Aged and Disabled Program to Provide Rural Health Clinic Services
• CMS-1561A Health Insurance Benefits Agreement
• HHS-690 Assurance of Compliance (if participating as a Medicaid RHC).
• CMS-2572 Statement of Financial Solvency, and Expression of Intermediary Preference
• RHC Regulations (Sections 491 and 405), Section 1861(aa) of the Social Security Act and the RHC Interpretive Guidelines

Note: Please contact the CMS Regional Office nearest you to obtain these forms or to learn where to download them from the Internet. Any form numbers listed in this chapter are subject to change and it is recommended that applicants check with CMS to ensure they have the proper form numbers.

The State agency, in an effort to better assist applicants in preparing for the RHC site visit, may request additional information such as: Clinic contact name and position, clinic phone and fax numbers, travel directions to the clinic from the State agency, clinic floor plan, hours of operation, clinic organizational chart, practitioner (physician, PA, NP or CNM) resumes and work schedules, and copies of the Advisory Meeting Minutes. If your state requires that you be licensed, you must obtain this license prior to being approved as a Medicare provider.

If you are applying as an Independent RHC (i.e. not an integral and subordinate part of a hospital, skilled nursing facility, or home health agency), you will request the CMS 855A Medicare Federal Health Care Provider/Supplier Enrollment Application from one of the Independent RHC Fiscal Intermediaries (FI) (A list of Independent RHC Fiscal Intermediaries can be found in Appendix F). If you are applying as a Provider-based RHC (i.e. integral and subordinate part of a hospital, skilled nursing facility, or home health agency), you will request the CMS 855A Medicare Federal Health Care Provider/Supplier Enrollment Application from the host provider's current fiscal intermediary (FI). The application can also be obtained online at http://cms.hhs.gov/providers/enrollment/forms/

If you are considering RHC designation for more than one site, you must complete a separate RHC application and CMS 855A for each site. The exception would be for those separate services that are co-located in the same office and share resources. Consider, for example, a facility that operates a pediatric practice on one side of the facility and an OB/GYN practice on the other side of the facility. Both share a common reception area, medical records, laboratory, break areas, staff and employer identification number (EIN). For the purposes of the RHC program, this would be considered one clinic, and only one application should be filed.

Request to Establish Eligibility to Participate in the Health Insurance for the Aged and Disabled Program to Provide Rural Health Clinic Services (Please contact the CMS Regional Office to obtain this form)

1. Identifying Information

   Insert the full name under which the clinic operates. A Rural Health Clinic site is the location at which health services are furnished. If a central organization operates more than one clinic site, a separate Request to Establish Eligibility Application for each rural health clinic site must be submitted. In these instances, the location of the health clinic site, rather than the central organization, will determine eligibility to participate. Also, the applicant site must be situated in a rural area, which is designated as underserved as discussed in Chapter Two. If the name of the rural health clinic site does not identify the owner(s), the name and address of the owner(s) is to be inserted in the space provided. Otherwise, that space is to be left blank.

2. Medical Direction

   Insert the name and address of the physician(s) responsible for providing medical direction for the health clinic site. The physician providing medical direction must be a member of the clinic's staff. RHC Code of Federal Regulations, sections 491.7, 491.8, 491.9, and 491.10, outline the roles and responsibilities of the Medical Director. To view these on-line, go to: www.narhc.org.

3. Clinic Personnel

   (A), (B), and (C) - Personnel are to be described in terms of full-time equivalents. To arrive at full-time equivalents, add the total number of hours worked by personnel in each category in the week ending prior to the week of filing the request and divide by the number of hours in the standard work week (as determined by clinic policies). If the result is not a whole number, express it as a quarter fraction only (e.g., .00, .25, .50, or .75). Exclude all trainees and volunteers. A nurse practitioner, certified nurse midwife and/or physician assistant (mid-level provider) in addition to the physician, is required for clinic eligibility and must be shown in B and/or C respectively. (D) - Where other types of personnel are utilized (e.g., technicians, aides, nurses, etc.), the discipline, by name, is to be indicated in addition to the full-time equivalents. (Example, RN - 1.5 FTE, CMA 2.0 FTE) The mid-level providers must be available to furnish patient care services at least 50% of the time the clinic operates. Upon initial application, the clinic may not request a temporary waiver of mid-level staffing requirements.

4. Type of Control

   Identify the RHC in terms of its control by checking the appropriate part of A - Individual (Profit or Non-profit), B - Corporate (Profit or Non-profit), C - Partnership (Profit or Non-profit), or D - Government (State, Local or Federal). Non-profit status is based on Internal Revenue Service tax exemption interpretation, i.e., Section 501 of the Internal Revenue Code of 1954. If the RHC is applying as a Provider-based clinic then you must include the Medicare number of the host entity on line (RH 11). By doing so, you are indicating: 1) that both the RHC and the host entity are licensed as a single health entity; 2) that the RHC and the host entity are subject to the bylaws and operating decisions of the same governing body; and 3) that the medical personnel of the RHC are considered by the governing body to be subject to the rules of the host entity's medical staff.

5. Signature

   An authorized official of the organization must sign the form (e.g., owner, Practice Manager, CEO, CFO, Board President.)

CMS 1561A Health Insurance Benefits Agreement

Two originals of this form must be completed, signed and included in the RHC application packet. Once the clinic has successfully passed the RHC certification survey and enrolled in the RHC Medicare program, the Secretary of Health and Human Services will sign the originals and one will be sent back to the clinic for their files.

HHS 690 Assurance of Compliance

An RHC is required to comply with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, and the Age Discrimination Act of 1975, if it chooses to participate in Medicaid as an RHC. If RHC status is chosen only for Medicare, compliance with the Civil Rights Act is not required. Some States have not required this signed assurance as part of the RHC application. Be aware that it is a requirement and you may be asked to complete the form.

CMS 2572 Statement of Financial Solvency

This is for the purpose of establishing eligibility for payment under Title XVIII of the Social Security Act. The provider of services States that they have not been adjudged insolvent or bankrupt in a State or Federal court; and that a court proceeding to make a judgment of bankruptcy or insolvency with respect to the provider of services is not
pending in a State or Federal court. While some States have not required this signed declaration as part of the RHC application, be aware that you may be asked to complete the form.

Once the RHC application documents have been completed, signed and dated, submit them to the responsible State agency. Remember to retain a copy of documents for your file.

CMS 855A Medicare Federal Health Care Provider/Supplier Enrollment Application

The CMS 855A was implemented on January 1, 2002, as part of changes mandated by the BBA (Balanced Budget Act) of 1997. This form, although much simpler than previous versions, is best understood by following the accompanying instructions. It is important to understand that several sections of the form do not apply to the initial enrollment and can be skipped. See the table for Sections that must be completed by an RHC site filing an initial application. Once completed, submit the CMS 855A with attachments to the FI for review and approval.

* This section is to be completed with information about all organizations that have 5 percent or more (direct or indirect) ownership interest of, or any partnership interest in, and/or managing control of the provider identified in this application, as well as any information on adverse legal actions that have been imposed against that organization. If there is more than one organization, copy and complete this section for each.

** This section is to be completed with information about any individual that has a 5 percent or greater (direct or indirect) ownership interest in, or any partnership interest in the provider identified in this application. All officers, directors, and managing employees of the provider must also be reported in this section. In addition, any information on adverse legal actions that have been imposed against the individuals reported in this section must be furnished. If there is more than one individual, copy and complete this section for each.

Once both packets have been submitted to their respective agency, they will be reviewed simultaneously (see RHC Application Matrix). The RHC packet will be reviewed by the State agency and the CMS 855A will be reviewed by the appropriate FI. Once the FI has approved the CMS 855A, a letter will be sent to the provider and the State agency informing them of the recommendation of approval. The provider will also be informed in their letter that the State agency will be contacting them regarding their date of readiness for the RHC survey. Once the State agency has received the recommendation letter from the FI and they have reviewed the RHC application packet for completeness, a letter will be issued to the provider informing them that they are eligible for the RHC program. The State agency may, but is not required to, instruct the provider to respond back to them in writing regarding their date of readiness for the RHC survey. When you respond with your date of readiness, you are indicating to the State agency, that as of that date, you believe you are, to the best of your ability, in compliance to with the RHC program regulations. You must be in operation and providing services to patients when surveyed. This means at the time of the survey the clinic functions as a RHC, and is serving a sufficient number of patients so that compliance with all requirements can be determined. This may be as few as one (1) patient, but only if, in the surveyor's judgement, compliance can be determined.

Currently CMS expects the state survey agencies to attempt to schedule initial surveys within 90 days of receiving notification that the 855 process is complete, assuming the provider is open and operating.

The State agency does have the option, under certain circumstances, of giving clinics a 48-hour notice of the scheduled survey. Some States, however, will not exercise this option and the survey will be unannounced.

Clinics are encouraged to begin collecting the information needed for completing the cost report. Although this report will not be filed until after the clinic is certified, you can use this time to make preliminary preparations so as to expedite the filing once certification is granted.