Chapter 19: Eligibility Requirements For Look-Alike Initial Designation Applicants

• Patient services utilization report (for example, from the Electronic Health Records (EHR)) from within the past 6 months. Data should include type of services and how the service was provided (Column I, II, or III).
• Five health center patient records¹ that document the provision of General Primary Medical Care services.
  Notes:
  • The same sample of patient records used for reviewing other program requirement areas may also be used for this sample.
  • Use live navigation of the EHR, screenshots from the EHR, or other patient record formats.
• All Sliding Fee Discount Schedules
• Applicant’s current organization charts with names of key management staff.
• For public agencies or for organizations with a parent or subsidiary: Corporate organization charts.
• Project Director/CEO position description.
• Project Director/CEO employment agreement.
• Most recent annual audit and management letter. If audits are not available, the most recent:  Audited financial statements.
• Sample of up to three Medicare or Medicaid claims or other billing documents. The sample should show the organizational entity or unit that conducts the billing.
• Bylaws (if updated since last application submission to HRSA).
• For public agencies with a co-applicant: Co-applicant agreement (if updated since last application submission to HRSA).
• Board minutes for the most recent 12 months.
  Note: If the applicant does not have 12 months of board minutes, all of the available board minutes from within the past 12 months.
• If the applicant has contracts or agreements that support the proposed Health Center Program scope of project (i.e., to provide health center services or to acquire other goods and services), provide a complete list of these contracts and agreements that includes:
  • All active contracts and agreements;
  • All contracts and agreements that had a period of performance that ended less than 3 years ago; and
  • The following information for each contract and agreement:
    • Name of organization;
    • Brief description of all goods and services provided;
    • Period of performance/timeframe (for example, specific duration, ongoing contractual/agreement relationship); and
    • Whether the contract or agreement indicates a third party plays a substantive role in the Health Center Program project (for example, a contract or agreement with a single entity for the majority of: health care providers and services, key management staff, or administrative functions).
• All contracts or agreements based on the list above, excluding contracts or agreements for the acquisition of supplies, material, equipment, or general support services (for example, janitorial services).
• If the applicant has a parent corporation, affiliate, subsidiary, or other controlling organization: All related agreements or other documentation.
• Documentation (for example, employment contracts) that shows the organization is not owned, operated, or controlled by another entity.

The applicant must:

• Be operational and currently providing all required primary health services;
• Currently provide primary health services as the health center’s main purpose;
• Make services accessible to all; and
• Have at least one service delivery site that is a permanent, fixed building location that operates year-round and for at least 40 hours per week. (For Migratory and Seasonal Agricultural Workers (MSAW) health center applicants, this site may be permanent or seasonal).

Site Visit Team Methodology

• Tour sites where a variety of services are provided directly by the applicant. If the applicant has more than one service site, tour at least two service sites.
• Review the following application-related materials submitted to HRSA:
  • Project Narrative Response Section;
  • Form 1A: General Information Worksheet;
  • Form 5A: Services Provided, General Primary Medical Care service delivery methods; and
  • Form 5B: Service Sites.
• Review patient services utilization report.
• Review five health center patient records that document the provision of General Primary Medical Care services.
• Review all Sliding Fee Discount Schedules.
• Interview Project Director/CEO, CMO, and other clinical staff responsible for service delivery.

Notes:

• The applicant may include a mobile medical unit as a site in scope only if the applicant listed at least one full- time, permanent site on Form 5B: Service Sites.
• The applicant may include a school-based service delivery site if:
  • The site is a permanent, full-time site or is proposed in addition to a permanent, full-time site.
  • The applicant showed in the Response section of the application Project Narrative how the applicant will ensure that the entire underserved population in the service area has access to all required services.
• The same sample of patient records used for reviewing other program requirement areas may also be used for this sample.
• Use live navigation of the Electronic Health Record (EHR), screenshots from the EHR, or other patient record formats.

Site Visit Findings

2. Is the applicant currently operational and providing all required primary health services?

   Response is either: Yes or No

   If No, an explanation is required.

3. Does the applicant currently provide General Primary Medical Care services either directly (Column I) or via one or more contracts (Column II)?

   Note: General Primary Medical Care cannot be provided solely by formal written referral arrangements (Column III).

   Response is either: Yes or No

   If No, an explanation is required

4. Does the health center have any referral arrangements (Column III) to provide General Primary Medical Care services?

   Response is either: Yes or No

   If Yes, an explanation is required, describing why and which patients are referred for General Primary Medical Care services. 

5. Does the applicant make services accessible to all?

   Note: The applicant may not propose to serve only a single age group or address a single health issue or disease. If the applicant targets a sub-population, for example children, the applicant must explain how the applicant will make all required services available to the entire underserved population in the service area.

   Response is either: Yes or No

   If No, an explanation is required.

6. Does the applicant have at least one service delivery site that is a permanent, fixed building location that operates year-round and for at least 40 hours per week?

   Note: For Migratory and Seasonal Agricultural Workers (MSAW) health center applicants, this site may be permanent or seasonal.

   Response is either: Yes or No

   If No was selected, an explanation is required.

The applicant must:

• Not be owned, controlled, or operated by another entity;
• Own and control the organization’s assets and liabilities;
• Have safeguards in place to ensure the benefits from being a look-alike stay within the proposed look-alike scope of project;
• Not have a sole corporate member and not be a subsidiary of another organization;
• Perform a substantive role in the project;
• For Residents of Public Housing (RPH) health center applicants: Consult with residents of the applicant’s public housing site(s) on the planning and ongoing operation of the proposed look-alike (LAL) sites.

Site Visit Team Methodology

• Review the following application-related materials submitted to HRSA:
  • Project Narrative Capacity and Governance sections; and
  • Form 8: Health Center Agreements.
• Review the applicant’s current organization charts.
• Review the Project Director/CEO position description and employment agreement.
• Interview Project Director/CEO about the day-to-day oversight of health center activities.
• Interview the applicant organization’s Project Director/CEO, CFO, financial staff, and board members (for example, board chair, board treasurer) about ownership and operation of the applicant organization.
• Review the most recent annual audit and management letter of the applicant organization. If audits are not available, review the most recent financial statements of the applicant organization.
• Review the Medicare or Medicaid claims or other billing documents that show the organizational entity or unit that conducts the billing.
• Review the bylaws of applicant organization and any co-applicant agreement for a public agency applicant with a co-applicant governing board.
• Review the board minutes for the most recent 12 months. 
  Note: If the applicant does not have 12 months of board minutes, all of the available board minutes from within the past 12 months.
• Review the complete list of contracts and agreements to identify those that indicate a substantive role in the Health Center Program project.
• Review all contracts and agreements to determine if any contracts or agreements impede or prohibit the applicant from performing a substantive role in the Health Center Program project.
• If the applicant has a parent company, affiliate, subsidiary or other controlling organization, review all related agreements or other documentation to identify if the parent company, affiliate, subsidiary or other controlling organization:
  • Plays a substantive role in the Health Center Program project; or
  • Impedes or prohibits the applicant from performing a substantive role in the Health Center Program project.
• Review any additional documentation (for example, employment contracts) that shows the organization is not owned, operated, or controlled by another entity.  
• Interview key management or other staff involved in procurement or contract oversight.
• For RPH health center applicants: Review the Project Narrative Governance Section and Form 6B: Request for Waiver of Board Member Requirement in the application-related materials submitted to HRSA.
   

Site Visit Findings

7. Does the applicant own and control its assets and liabilities?

   Response is either: Yes or No

   If Yes OR No, an explanation is required specifying how the assets and liabilities of the applicant organization are owned and controlled.

8. Does the applicant have safeguards in place to ensure the benefits from being a look-alike stay within the proposed look-alike scope of project?

   Response is either: Yes or No

   If YES OR No, an explanation is required.

9. Does the applicant have a sole corporate member or is the applicant a subsidiary of another organization?

   Response is either: Yes or No

   If Yes, an explanation is required.

10. To help determine if the applicant performs a substantive role in the project:

    • 10.1 Are any of the applicant’s clinical and administrative functions provided through contractors or through a single affiliated or related organization?

      Response is either: Yes or No

    • 10.2 Are any of the applicant’s key management staff (CEO, CMO, CFO, etc.) not directly employed by the applicant?

      Note: The CEO must be directly employed by the applicant.

      Response is either: Yes or No

    • 10.3 Do any of the applicant’s relationships or agreements with other entities restrict or infringe upon the applicant board’s required authorities and functions?

      Response is either: Yes or No

    • 10.4 Do the applicant’s key management staff or board members also work for an affiliated or related organization?

      Note: Affiliated or related organizations are those that provide financial or other support to the applicant organization.

      Response is either: Yes or No

    • 10.5 Are there any other factors that impede or prohibit the applicant from performing a substantive role in the Health Center Program project?

      Response is either: Yes or No

      If any of the above are Yes, an explanation is required. If there is another affiliated or related organization, include the organization name and details on how the organization is affiliated or related to the applicant.

11. Based on your findings in questions 7-10, did the applicant demonstrate that it is NOT owned, controlled, or operated by another entity?

    Response is either: Yes or No

    If Yes OR No, an explanation is required.

12. Is the applicant a Residents of Public Housing health center applicant?

    Response is either: Yes or No

13. If YES: Has the applicant consulted with residents of the applicant’s public housing sites on the planning and ongoing operation of the proposed LAL sites?

    Response is either: Yes or No

    If No, an explanation is required.