Comments & Response on DRAFT Policy Information Notice, “Policy for Change in Scope Request to Add a New Target Population”
On August 8, 2007, the Health Resources and Services Administration (HRSA) made the draft Program Information Notice (PIN), “Policy for Change in Scope Requests to Add a New Target Population,” available for public comment on HRSA’s web site. The purpose of the PIN is to describe the factors that will be considered by HRSA when evaluating change in scope requests for prior approval from health centers to add a new target population beyond the designated population for which Federal grant funds were awarded. Comments were due to HRSA by October 19, 2007.
Over 30 comments were received from 12 organizations and/or individuals regarding the draft PIN. After review and careful consideration of all comments received, HRSA amended the PIN to incorporate certain recommendations from the public. The final PIN, “Policy for Special Populations-Only Grantees Requesting a Change in Scope Request to Add a New Target Population,” reflects these changes.
The purpose of this document is to summarize the major comments received and convey the agency's response, including any corresponding changes made to the PIN. Where comments did not result in a revision to the PIN, explanations are provided.
Issue: Appropriateness of the Policy
Comments
Most commenters supported the publication of this PIN stating the need for an updated policy defining the criteria for prior approval for health centers requesting changes to their approved scope of project to add a new target population. Commenters appreciated the transparency and accountability of this draft policy and the commitment of HRSA to assure that all programs that serve an additional target population will be required to meet all of the applicable program requirements and expectations. Commenters also appreciated the recognition that changes in target population should be viewed from an organizational perspective, rather than on a site-by-site basis, thus limiting administrative burden for centers attempting to address certain minimal fluctuations within their communities.
HRSA Response
HRSA recognizes that health centers are a critical component of the Nation’s health care safety net and in order to continue to provide services to the underserved and uninsured, policies must be updated to align with current health care changes at the local level. The PIN was developed with the goal of providing health centers with clear criteria for requesting changes to their approved scope of project to add a new target population beyond that for which they receive funding.
After careful consideration, HRSA determined that the policies of the draft PIN did not apply to health centers funded under section 330(e) because these health centers receive funding to serve general underserved populations (including migratory and seasonal farmworkers, homeless individuals and residents of public housing) and are not restricted in the use of their grant funds and related resources to serving a specific statutorily defined target population as are health centers receiving funding only under section 330(g), (h), and/or (i). Therefore, the final PIN reflects this updated determination.
Issue: General Clarifications/Updates/Consistency/Duplication
Comments
A number of the comments suggested the use of common, consistent terminology and more detail in certain areas to provide greater clarity. Further, several commenters suggested that this PIN be combined with other documents as one comprehensive scope of project PIN to reduce duplication and grantee burden in relying on several different documents on the same general topic.
HRSA Response
With regard to consistency within the PIN, the document has been reviewed and edited to ensure that the guidance provided to grantees is consistent throughout all sections of the document. This PIN is designed to be used in conjunction with PIN 2008-01, “Defining Scope of Project and Policy for Requesting Changes,” issued on December 31, 2007 (http://www.bphc.hrsa.gov/policy/pin0801/). As specific areas pertinent to scope of project emerge, it is HRSA’s intent to issue supplementary guidance to PIN 2008-01 to provide direct and relevant guidance on that particular issue.
Issue: Funding Distribution and Reallocation of Funds among Health Center Program Subparts
Comments
There were many diverse comments submitted regarding the expectations for funding distribution and reallocation of funds among the Health Center Program subparts (sections 330(e), (g), (h), and (i)). One commenter suggested any funds taken away from a specific subpart of the Health Center Program (e.g., Community Health Center, Migrant Health Center, Health Care for the Homeless or Public Housing Primary Care) through the reallocation of grant funds under a change in scope request be credited back to the program(s) to assure funds are allocated under the statutory proportional funding requirement. In addition, a commenter suggested that the reallocation of funding was not necessary because all section 330 grants (including those awarded under section 330(g), (h) and (i)) are technically made under the general authority of section 330(e) and, therefore, no targeted funding should be reallocated among the subparts. Further, it was suggested that health centers should be allowed to support such changes in target population through non-Health Center Program funds if these are sufficient to cover all costs (direct and indirect) for services to a new population. One commenter suggested that support for a new target population should only be considered through the competitive grant application process. One commenter also suggested that once a health center is funded, HRSA should not reallocate a grantee’s distribution of funds without prior notification and consent.
Several commenters also noted that the draft PIN was inconsistent in requiring a health center to demonstrate that a portion of their HRSA grant funds be reallocated to support services to the new population with the concurrent requirement in Attachment A that the health center’s change in scope request not shift resources from support of the current target population. Several commenters also suggested that HRSA either eliminate the criterion in the Attachment A or modify it so that a grantee may demonstrate a shift resources used to support the existing target population.
HRSA Response
The Health Center Program’s authorizing statute requires that grant funds appropriated for section 330 be distributed among the various categories of health centers in a specific proportional manner (section 330(r)(2)(B) of the Public Health Service (PHS) Act). In order to assure that the section 330 funds are used for the purposes intended by Congress, health centers must utilize their grant funds and related grant-supported resources (such as program income) included as part of the total project budget, to support services for the specific population for which section 330 funds were awarded. Special-populations only grantees that seek to add a new target population are required to demonstrate that a portion of their existing section 330 funds will be reallocated to the appropriate section 330 subpart necessary to support the new population. HRSA will not unilaterally re-allocate a health center’s grant funds; any reallocation of funding will be done in consultation with the grantee (as described on page 8 of the PIN) as part of a change in scope request and in a manner that assures the Health Center Program’s continued compliance with the statutorily mandated funding distributions. HRSA will only reallocate funds if a special populations-only Health Center Program grantee’s change in scope request to add a new target population is approved.
If a health center chooses to provide services to another target population without using Health Center Program funds and/or other related resources included as part of the total project budget, it may do so as a separate line of business outside of the approved scope of project. Section III of PIN 2008-01, “Defining Scope of Project and Policy for Requesting Changes,” provides further information on health center activities that are not part of a health center’s Federal scope of project. However, all activities conducted outside of a health center’s approved scope of project are not authorized to receive FQHC benefits.
The “Policy for Special Populations-Only Grantees Requesting a Change in Scope Request to Add a New Target Population” PIN addresses the factors that HRSA will consider when health centers funded only under sections 330(g), (h), and/or (i) of the PHS Act request to add a new target population to its scope of project beyond the designated population for which Federal grant funds were awarded. The final PIN does not apply to health centers funded under section 330(e) because these health centers receive funding to serve general underserved populations (including migratory and seasonal farmworkers, homeless individuals and residents of public housing) and are not restricted in the use of their grant funds and related resources to serving a specific statutorily defined target population. A special populations-only health center is required to submit a request for prior approval to HRSA for changes in scope of project that are considered significant (e.g., more than 25 percent of the health center’s patient population is/will not be not part of the designated target population for which funds were awarded) and can be accomplished without any additional grant funds. Only those grantees that can support services to both the existing and new target population within the current approved level of section 330 funding will be approved. If an existing special populations-only grantee requires additional section 330 grant funds to support services for the new target population, it should consider submitting a grant application under an announced competitive funding opportunity.
HRSA has addressed the inconsistency identified in the Draft PIN and the requirement in Attachment A that the change in scope request will not shift resources from support of the current target population. The final PIN has been amended to assure that the issues concerning the expectations for funding distribution and reallocation of funds among the Health Center Program subparts have been addressed.
Issue: Requirement to Maintain Level of Service for the Existing Target Population
Comments
There were many diverse comments submitted regarding the requirement to maintain the level of service for the existing target population. Many commenters supported the expectation for a health center to demonstrate maintenance of effort for the existing target population as part of a request to add a new target population; however, many commenters also suggested that it may be difficult for a health center that currently serves a large underserved and uninsured population to redirect a portion of its current funding to serve another population without creating a negative impact on access to care for the current target population.
Several commenters noted that the Draft PIN was inconsistent in requiring that a health center add the new target population with the requirement in Attachment A that the current level of services be sustained. Several commenters also suggested that HRSA either eliminate the criterion in the Attachment A or modify it so that, if justified through a change in scope request, a health center may demonstrate a shift in the level of services and number of patients served between the original and the new target population as long as the health center will maintain the same overall (organizational) level of services and total number of patients.
Several commenters noted that the requirement for a health center to maintain its level of service to the current target population does not provide an allowance for more significant, long-term environmental and/or demographic changes. These changes impact the need for equivalent access to care for the current target population and the commenters suggested that HRSA allow more flexibility in this policy to account for scope of project change requests which are a result of a considerable fluctuation or decline in the existing target population. In contrast, some commenters suggested that the provision in the Draft PIN allowing Health Center Program grantees to describe “any unique circumstances” that will impact on their ability to meet the HRSA expectation to maintain the same level of services to its current target population, may indirectly allow a health center to gradually reduce maintenance of effort while simultaneously redirecting its resources to the new population. Other commenters appreciated HRSA’s recognition that a health center may experience minor fluctuations in its target population for a variety of reasons and that these fluctuations should be viewed from an organizational perspective rather than on a site-by-site basis and should not trigger the need for a change in scope request.
HRSA Response
While recognizing that there may be unique local circumstances impacting the community and/or target population, the addition of a new target population should not result in the diminution of a health center’s level of health services currently being provided to the existing target population for which funds were originally awarded. A special population-only health center approved to add a new target population is expected to maintain the level of service to its existing target population for which funds were awarded, to the extent possible, recognizing that there may be unique circumstances that affect the ability of the health center to fulfill this expectation.
A special populations-only health center requesting to add a new target population must propose that a portion of its current section 330 funding (section 330(g), (h), and/or (i)) be reallocated to support services to the new population and provide a breakout of the projected patients for both the current target population and the new population to be served. HRSA has also addressed the inconsistency identified in the draft PIN and Attachment A with respect to the requirement to maintain the level of services, to the extent possible, to the existing population.
The final PIN has been updated to address concerns raised regarding gradual and/or significant changes that may impact the demand for services from the existing target population and, therefore, the ability of the health center to maintain its current level of service. HRSA agrees that there may be cases where a health center has experienced dramatic changes in its service area, resulting in substantial reductions in demand from the current target population and making it difficult for the health center to maintain its current target population levels. To address this issue, the PIN states that health centers will be given the opportunity to document any unique circumstances that are expected to impact their ability to meet this expectation and how these circumstances can be mitigated.
Issue: Need for Prior Approval
Comments
Several commenters suggested that no prior approval should be required for a health center to add a new target population. Others requested greater clarification as to when a health center must seek prior approval to add a new target population. One commenter also recommended that HRSA require a health center requesting to add a new target population, document that it has exhausted all possible attempts/measures to identify and serve their current target population before a change in scope of project to add a new target population is approved.
HRSA Response
As stated in PIN 2008-01, some changes in the approved scope of project require prior approval from HRSA before being initiated; others may be implemented by the health center without prior approval. The expansion of the target population(s) of a special populations-only grantee beyond the designated population for which section 330 funds have been awarded (e.g., more than 25 percent of the health center’s patient population is not part of the defined target population(s)), is considered a significant change in scope requiring prior approval from HRSA. This change in scope to add a new target population may be done in conjunction with, or independent of, a change in scope request to add/delete/relocate a site or add/delete a service. However, if a proposed change in scope (i.e., adding a new site) does not expand the health center’s target population beyond that for which funding was awarded, the health center does not need to include a request to expand the target population in its request for prior approval.
Special populations-only health centers are expected to demonstrate that all required primary health services are available to all patients before proposing to add a new target population and that the addition of a new target population will not compromise the provision of required primary health services to the existing patient population. In consideration of a request to add a new target population, the PIN reiterates that special populations-only health centers are expected to demonstrate that the change in scope will not have a negative impact or diminution on the level of service to the existing target population.
Issue: Impact on Neighboring Health Centers
Comments
A few commenters noted that the PIN should require a process allowing other organizations, including any potentially affected neighboring health centers, to provide their input on a Health Center Program grantee’s request to add a target population prior to HRSA’s decision. Further, commenters suggested that a request that may create a service area overlap should require validation from the board of the neighboring health center. One commenter recommended that HRSA develop a more formal process whereby both the requesting and neighboring health centers must present documentation and data to support their position regarding a request to add a new target population.
HRSA Response
It is HRSA’s expectation that health centers coordinate and collaborate with other local health service providers serving underserved populations in the same or adjacent service areas. Section 330 of the PHS Act specifically requires that applicants for health center funding have made and/or “continue to make every reasonable effort to establish and maintain collaborative relationships with other health care providers in the catchment area of the center” (PHS Act section 330(k)(3)(B)). The goal of collaboration is to utilize the strengths of all involved organizations to best meet the overall health care needs of the area’s underserved populations.
Regarding the suggestion that health centers should be expected to contact the Board of Directors of a neighboring health center when adding a new target population, HRSA continues to expect health centers to collaborate with other area providers and to include with a change in scope request, a Board of Directors-endorsed letter of support from any neighboring health centers or an explanation why such a letter(s) cannot be obtained. For further information on service areas, grantees should refer to PIN 2007-09: Service Area Overlap: Policy and Process (http://www.bphc.hrsa.gov/policy/pin0709.htm).
Issue: Including Other Populations in Scope of Project
Comments
One commenter suggested that HRSA clarify whether services to a population that are supported through other HRSA programs, such as the Ryan White HIV/AIDS Programs, can be supported/included under a Health Center Program grantee’s scope of project.
HRSA Response
HRSA recognizes that a health center may include diverse funding sources as part of its total budget to support services to its target population. If the population served/to be served by a Health Center Program grantee under another HRSA grant program (e.g., the Ryan White HIV/AIDS Programs) is consistent with the population for which section 330 funds were awarded, these additional HRSA funds may be included as part of their overall section 330 project budget without impacting on the Health Center Program grantee’s scope of project. As such, the services provided/required under both grant programs would be included in the scope of project and must be available to everyone served by the health center. If the population served/to be served under another HRSA program is (1) not consistent with the target population supported under the section 330 scope of project, and (2) if added to the section 330 scope of project, the patients served under the non-Health Center Program would represent a significant portion of the health center’s patients (e.g., more than 25 percent), then the health center may either request a change in scope to add the non-Health Center Program population as a new target population or maintain services to the non-Health Center Program population outside of the section 330 scope of project as another line of business.
Issue: Grandfathering
Comments
Many commenters requested clarification from HRSA on the expectation for grandfathering of existing/previously approved arrangements that are within a Health Center Program grantee’s approved scope of project. Many suggested that the current arrangements should be allowed to remain in scope regardless of policy changes, provided that the health center can provide adequate justification.
HRSA Response
As necessary, HRSA will provide all Health Center Program grantees with an opportunity to modify and/or update their scope of project information to assure that every grantee’s scope of project is consistent with current policies. If there are any discrepancies, HRSA will work with health centers to resolve any potential issues.
