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 patient demographics, type of services, and how the service was provided (Column I, II, or III).
• Five health center patient records¹ that document the provision of various required and additional health 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. 
• 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: 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).
• If the applicant has contracts or memoranda of understanding (MOUs) 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 MOUs that includes:
  • All active contracts and MOUs;
  • All contracts and MOUs that had a period of performance that ended less than 3 years ago; and
  • The following information for each contract and MOU:
    •  Contractor or contract/MOU organization; 
    • Brief description of all goods and services provided; 
    • Period of performance/timeframe (for example, specific duration, ongoing contractual/MOU relationship); and 
    • Whether the contract or MOU indicates a third party plays a substantive role in the Health Center Program project (for example, a contract or MOU with a single entity for the majority of: health care providers and services, key management staff, or administrative functions).
• Any and all contracts or MOUs that indicate a third party plays a substantive role in the Health Center Program project (for example, a contract for the majority of health care providers and services, a contract for the majority of key management staff, an administrative services agreement for the majority of administrative functions).
• 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.

An organization applying for look-alike designation must demonstrate to HRSA that it is currently delivering primary health care services to patients within the proposed service area.

Site Visit Team Methodology

• Tour service delivery sites (one or more sites on Form 5B).
• Review the patient services utilization report.
• Review the five health center patient records that document the provision of various required and additional health 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 Electronic Health Record (EHR), screenshots from the EHR, or other patient record formats.

Site Visit Findings

2. Is the applicant CURRENTLY delivering primary health care services to patients within the proposed service area?

   Response is either: Yes or No

   If No, an explanation is required.

3. Does the health center have at least one permanent service delivery site that:
   
   Note: A permanent site is a fixed location that operates year-round. 
   • 3.1 Provides comprehensive primary medical care as the site’s main purpose?

     Response is either: Yes or No

   • 3.2 Operates for a minimum of 40 hours per week?

     Note: Only select “Not Applicable” if the health center is applying for designation to serve only migratory and seasonal agricultural workers, in which case the health center may have a full-time seasonal rather than permanent site.

     Response is: Yes, No, or Not Applicable

   If No was selected for any of the above, an explanation is required.

4. IF NOT APPLICABLE: Does the health center serving only migratory and seasonal agricultural workers have at least one full-time seasonal service delivery site?

   Response is either: Yes or No

   If No was selected, an explanation is required.

An organization applying for look-alike designation must demonstrate to HRSA that it is not owned, controlled, or operated by another entity. Specifically, the organization applying for look-alike designation:

• Owns and controls the organization’s assets and liabilities (for example, the organization does not have a sole corporate member, is not a subsidiary of another organization), and as such will be able to ensure that the benefits that accrue through look-alike designation as a Federally Qualified Health Center (FQHC) are distributed to the Health Center Program project (for example, FQHC payment rates, 340B Drug Pricing); and
• Operates the Health Center Program project. At a minimum, the look-alike applicant organization demonstrates that it maintains a Project Director/CEO who will carry out independent, day-to-day oversight of health center activities solely on behalf of the applicant organization’s governing board.

Site Visit Team Methodology

• 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 audited 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 complete list of contracts and MOUs to identify those that indicate a substantive role in the Health Center Program project.
• Review any and all contracts and MOUs that indicate a third party plays a substantive role in the Health Center Program project to determine if these contracts and MOUs 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 health center staff involved in procurement or contract oversight.

Site Visit Findings

5. Does the organization applying for look-alike designation currently OWN AND CONTROL the organization’s assets and liabilities? For example, the applicant organization does not have a sole corporate member or is not a subsidiary of another organization.

   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.

6. Does the organization applying for look-alike designation have safeguards in place to ensure the benefits that accrue through look-alike designation as a FQHC (for example, FQHC payment rates, 340B Drug Pricing Program eligibility) will only be distributed to the Health Center Program project?

   Response is either: Yes or No

   If No, an explanation is required.

7. Does the organization applying for look-alike designation operate the Health Center Program project? Specifically, the applicant organization operates the services and activities included in the look-alike application.

   Response is either: Yes or No

   If No, an explanation is required.

8. Does the organization applying for look-alike designation have a Project Director/CEO in place who carries out independent, day-to-day oversight of the health center services and activities included in the look-alike application, solely on behalf of the governing board of the applicant organization?

   Response is either: Yes or No

   If No, an explanation is required.

9. Did the organization applying for look-alike designation demonstrate that it will perform a substantive role in the Health Center Program project?

   Response is either: Yes or No

   If No, an explanation is required describing the contractual or organizational arrangements that impede or prohibit the applicant from performing a substantive role in the Health Center Program project (for example, a contract for the majority of health care providers and services, a contract for the majority of key management staff, an administrative services agreement for the majority of administrative functions).