DATE: January 14, 2009
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 information collection, control number 0915-0142, has been extended to November 30, 2011.
This OMB approval provides the Health Resources and Services Administration (HRSA) with the authority to continue to collect the data specified in PIN 2003-21 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 PIN 2003-21:
- Race and ethnicity data is now collected as two separate data elements in Table 2, Part B, to meet OMB 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 2003-21 when making submissions. Please note that all information 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 form 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.
If you have any questions regarding this PIN or the FQHC Look-Alike Program, please contact the Office of Policy and Program Development at 301-594-4300.
James Macrae
Associate Administrato
TABLE 1 - SERVICES OFFERED AND DELIVERY METHOD TABLE 2 - PATIENTS
TABLE
2 - PART A PATIENTS BY AGE AND GENDER
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Age
Groups |
Male Patients |
Female Patients |
Prenatal Patients |
1.) Under
age 1 |
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2.) Ages
1-4 |
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3.) Ages
5-12 |
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4.) Ages
13-14 |
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5.) Ages
15-19 |
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6.) Ages
20-24 |
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7.) Ages
25-44 |
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8.) Ages
45-64 |
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9.) Ages
65-74 |
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10.)
Ages 75-84 |
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11.)
Ages 85 and over |
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12.)
Total Patients |
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TABLE
2 - PART B PATIENTS BY ETHNICITY
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Ethnicity |
Number of Patients |
Number in Service Area |
1.) Hispanic or Latino |
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2.) Unreported/Unknown |
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3.) Total Patients |
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TABLE 2 - PART
B PATIENTS BY RACE
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Race//Language |
Number of Patients |
Number in Service Area |
1.) Asian |
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2.) American Indian or Alaska Native
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3.) Black or African American |
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4.) Native Hawaiian or Other Pacific
Islander |
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5.) White |
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7.) Unreported/Unknown |
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8.) Total Patients |
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9.) Patients Needing Interpretation
Services |
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TABLE 2 -
PART C PATIENTS BY INCOME LEVELS
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Percent of Poverty Level |
Number of Patients |
Number in Service Area |
1.) 100% and below |
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2.) 101 - 200% |
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3.) Above 200% |
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4.) Unreported/Unknown |
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5.) Total Patients |
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TABLE 2 - PART D PATIENTS BY PAYMENT
SOURCE |
Payment Sources |
Number of Patients |
Percent of Patients |
1.) Medicare |
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2.) Medicaid |
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3.) Other Public Insurance |
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4.) Other Third Parties |
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5.) Self-Pay |
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6.) Total Patients |
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100% |
TABLE
3 - PROVIDERS
Personnel
by Major Service Categories |
Total
FTEs |
Status
(Place “X” if Employed
directly “C” if by contract)
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State
License (Y/N) |
Hospital
Admitting Privileges (Y/N) |
Board Certified
(Y/N) |
Total Encounters
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Medical Providers (i.e., General Practitioners,
Internists, Obstetrician/Gynecologists,
Pediatricians, Other Physician Specialists,
Nurse Practitioners, Certified Nurse
Mid-Wives) |
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Dental Providers |
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(i.e., Dentists, Dental Hygienists)
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Mental Health & Substance Abuse
Providers |
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(i.e., Psychiatrists, other specialists)
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TABLE 4 - PATIENT SERVICE
CHARGES, COLLECTIONS, AND SELF-PAY ADJUSTMENTS
Payment
Source |
Full Charges
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Amount
Collected |
Adjustments
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Medicare |
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1.) Medicare Fee-for-Service |
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2.) Medicare Capitated |
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3.) Total Medicare (Lines 1 and
2) |
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Medicaid |
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4.) Medicaid Fee-for-Service |
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5.) Medicaid Capitated |
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6.) Total Medicaid (Lines 4 and
5) |
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Other Public Payers |
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7.) Other Public Fee-for-Service |
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8.) Other Public Capitated |
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9.) Total Other Public (Lines 7
and 8) |
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Other Third Party |
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10.) Other Third Party Fee-for-Service
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11.) Other Third Party Capitated |
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12.) Total Other Third Party (Lines
10 and 11) |
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Self-Pay |
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13.) Self-Pay |
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14.) Total (Lines 3, 6, 9, 12, and
13) |
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Self-Pay Adjustment Type |
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15.) Self-Pay Sliding Fee Adjustments
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16.) Other Self-Pay Adjustments (Self-Pay
Bad Debt and Charity Care) |
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17.) Total Self-Pay Adjustments (Lines
15 and 16) |
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TABLE 5 - CURRENT BOARD MEMBER CHARACTERISTICS
Total Number/Range of Members Established in By-Laws or
Articles of Incorporation:_______ Positions Filled:_____ as of __/__ / __
Name |
Board Office Held
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Patient Status
(Y/N) |
Area of Expertise
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Live (L) or Work
(W) in Service Area |
Years of Continued
Board Service |
1. |
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2. |
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3. |
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4. |
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5. |
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6. |
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7. |
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8. |
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9. |
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10. |
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Indicate # Board Members by Sex: F = __M = __
Indicate # Board Members by Race/Ethnicity:
White: Hispanic or Latino: _________
Black/African American: _________
Asian/Pacific Islander: American Indian & Alaska Native: _________
Notes: - Use additional pages if necessary.
- If board member is not a Patient (i.e., "N" in column 3) indicate if that member derives more than 10% of his/her income from the health care industry (e.g., “N > 10%” or “N < 10%”).
- 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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