As stated above, services provided
by primary care clinicians as part of
their ordinary scope of practice are
not considered specialty services; thus,
this PIN is not directly applicable
to requests to add such services to
the Federal section 330 scope of project.
Although prior approval is still necessary,
in general, the addition of services
listed as examples of “additional health
services” in section 330(b)(2) of the
PHS Act will be considered appropriate
for inclusion within the health center’s
Federal scope of project. These services
include: behavioral and mental health
and substance abuse services;18
recuperative care services; environmental
health services; and occupation-related
health services for migratory and seasonal
agricultural workers.
When reviewing a request to add specialty
services to the Federal scope of project,
HRSA will evaluate the request using
the factors listed below. These factors
were developed taking into consideration
HRSA’s goal of supporting the extension
of necessary health services to current
health center patients in support of
required primary health services while
ensuring that health centers continue
to (1) meet the current statutory, regulatory,
and policy requirements of the Health
Center Program and (2) comply with DHHS
grants regulations and policy.
Section 330 authorizes the provision
of “additional” health services “as
may be appropriate for particular centers”
when those services are “necessary for
the adequate support of the [required]
primary health services.”19
Therefore, when requesting a change
in scope to add a specialty service
to the Federal scope of project, a health
center must demonstrate how the new
service will support the provision of
the required primary care services provided
by the health center. In other words,
the health center must show that the
proposed services function as a logical
extension of the required primary care
services already provided by the health
center and/or that the proposed services
complement the required primary health
care services. Examples of services
that may be a complementary extension
of primary health care include:
- pulmonary consultations, and/or
examinations, where the health center
serves a substantial number of patients
with asthma, COPD, Black Lung, or
tuberculosis;
- cardiology screenings and diagnoses,
where the health center serves a substantial
number of patients at risk for heart
disease or high blood pressure;
- minor podiatry outpatient procedures
or examinations, where the health
center serves a population with a
high prevalence of diabetes;
- psychiatric consultations, examinations
and differential diagnoses, where
the health center serves a substantial
number of patients with mental health
and/or substance abuse diagnoses;
- periodontic services, where the
health center serves a significant
population of children with poor oral
health;
- colonoscopies; and
- appropriate oncological care of
health center patients with cancer.
B. Demonstrated
Need for the Proposed Specialty Service
Section 330 authorizes the provision
of non-required “additional” health
services when appropriate to meet the
needs of the target population. Therefore,
when requesting a change in scope to
add a specialty service to the Federal
scope of project, a health center must
demonstrate and document the target
population’s need for the proposed service.
Unmet need should be described both
in narrative format and with data.
In addition, when proposing the addition
of a specialty service, the health center
must demonstrate its ability to maintain
the level and quality of the required
primary health services currently provided
to the target population (see section
V above).
C. Funding/Budget/Financial
Risk
Any requested change in the Federal
scope of project must be fully accomplished
with no additional section 330 grant
support. In assessing the financial
impact of adding a service, a health
center should consider whether the service
will be considered a “FQHC service”
and, therefore, be eligible for enhanced
FQHC Medicaid/Medicare reimbursement.
In general, the site or service to be
added must be able to generate adequate
revenue to cover all expenses, including
overhead costs incurred by the health
center in managing the site or service.
If additional Federal funds will be
necessary to fully implement the change
in Federal scope, the grantee should
apply for competitive funding as appropriate,
with the awareness that Federal grant
dollars are limited. And, as stated
above, the provision of any additional
service must not compromise the provision
of required primary health care services.
In summary, when requesting a change
in Federal scope to add a specialty
service to the scope of project, a health
center must demonstrate that adding
the new service (1) will not jeopardize
the health center’s overall financial
stability and (2) will be accomplished
with no additional section 330 grant
funds.
D. Location
of the Service
In order to ensure that the proposed
new service will be accessible to health
center patients, and that the health
center will be able to maintain appropriate
control over service delivery, the service
must be provided at an approved site
(see definition above) within the Federal
scope of project, at a new site that
will be proximate to available FQHC
services,20 or
at a location where in-scope services
are provided but that does not meet
the definition of a service site. Therefore,
when requesting a change in the Federal
scope of project to add a specialty
service, a health center must (1) describe
the specific location of the proposed
service and (2) demonstrate that the
service will be provided at an approved
health center site, a proposed new site
proximate to available FQHC services
or at a location where in-scope services
are provided but that does not meet
the definition of a service site. In
all cases, health centers must ensure
that adequate and appropriate documentation
has been secured to support and enable
performance of the specialty services
(e.g., translation and transportation
services as needed).
If a specialty service is provided
at a location that does not meet the
definition of a service site, the health
center must document the manner by which
the referral will be made and managed
and the process for facilitating appropriate
follow-up care at the health center.
Additionally, health centers must ensure
services are provided in culturally
and linguistically appropriate manner
based on the target population(s).
And finally, once a service is included
in the approved scope of project, it
must be available equally to all patients
regardless of ability to pay and available
through a sliding fee scale according
to 42 C.F.R. 51c.303(f). Specifically,
the discounted fee schedule must provide
a full discount to individuals and families
with annual incomes at or below the
poverty guidelines (only nominal fees
that do not impede access to care may
be charged) and for those with incomes
between 100 percent and 200 percent
of poverty, fees must be charged in
accordance with a sliding discount policy
based on family size and income. No
discounts may be provided to patients
with incomes over 200 percent of the
Federal poverty level.21
Additional
Considerations
1. State Licensing:
Providers must be properly licensed,
according to their State or territory’s
laws, to be included within the health
center’s Federal scope of project.
Approval of a request to add providers
of new services to the Federal scope
of project is contingent upon the health
center’s demonstration that all providers
associated with the new service meet
the professional, State, and local qualifications
necessary to provide that service.
2.Credentialing and Privileging:
All providers must be properly credentialed
and privileged to perform the activities
and procedures expected of them by the
health center. “Credentialing” is the
process of assessing and confirming
the qualifications of a licensed or
certified health care practitioner.
“Privileging” is the process of authorizing
a licensed or certified health care
practitioner’s specific scope of patient
care services. Privileging is performed
in conjunction with an evaluation of
an individual’s clinical qualifications
and/or performance. It is the responsibility
of the health center to ensure that
all credentialing and privileging of
providers have been completed before
including a service in the Federal scope
of project. Therefore, a health center
requesting the addition of a specialty
service to the Federal scope of project
must demonstrate that the credentialing
and privileging requirements have been
met.22
3. Potential Staffing Arrangements/Corporate
Structure: Health centers utilize
a variety of mechanisms for provider
staffing. For instance, health centers
may directly employ or contract with
providers and/or have arrangements with
other organizations for clinical staffing
of the health center. Health centers
are encouraged to carefully consider
the benefits and risks associated with
various staffing arrangements because
each impacts health center costs and
operations differently. When evaluating
change in Federal scope requests, HRSA
will examine the proposed staffing arrangement
as part of a review of the impact of
the proposed change on the total organization
(e.g., whether the arrangement necessitates
an affiliation agreement). Therefore,
health centers requesting the addition
of a specialty service to the Federal
section 330 scope of project must provide
a clear and comprehensive description
of the relevant staffing arrangements
and describe any potential impact on
the overall organization.