N.J. Admin. Code § 10:66-4 app D

Current through Register Vol. 56, No. 11, June 3, 2024

Appendix D

Change In Scope Of Service Application Requirements

The following items must be completed for each change in scope of service incurred by a Federally qualified health center (FQHC). Items below, labeled as A, B, and C, must be submitted in narrative format to the Division of Medical Assistance and Health Services (DMAHS).

The item labeled D is the instructions for the Change in Scope of Service Certification Statement and Reporting Forms 1 through 5. THE INITIAL SUBMISSION MUST INCLUDE SEPARATE FORMS FOR EACH YEAR OF THE PHASE-IN PERIOD IN WHICH THE CHANGE IN SCOPE OF SERVICE OCCURS. Within five months of the completion of each phase-in year, complete the same forms with actual data and send hard copy with disk to DMAHS.

DMAHS reserves the right to request additional information as needed.

A. DESCRIPTION OF THE SERVICE AREA AND TARGET POPULATION

1. List address(es) where the change in scope of service will occur.

2. Describe the service area(s)/community(ies) to be served by the new program.

3. Describe the target population(s) within the service area. Attach a copy of the target population submitted to HRSA (Form 3) and explain in detail any differences.

4. Describe how many people will be served and the number of projected encounters for each location for each year during phase-in, up to and including the year in which the new program will be fully implemented.

5. Attach a copy of the Notice of Grant Award or the approval letter from the Health Resources and Services Administration (HRSA) or state that it is not reviewable by HRSA.

B. SERVICE DELIVERY MODEL

1. Provide an overview of the service delivery model of the new program or services.

2. Describe whether and/or how the project expands upon or replaces pre-existing services.

C. BUDGET NARRATIVE

1. Discuss the appropriateness and reasonableness of the annualized budgets for each year during the phase-in period in terms of:

(a) Staffing: Describe how health care services will be provided--via staff providers, contract and/or through referral. Describe clinical staffing pattern (for example, number and mix of primary care physicians and other providers and clinical support staff, language and cultural appropriateness, etc.) of the new program or service. Have the clinical and other staff members for the new program or service been hired and if not, when will they start working? What is the plan for phasing in the staff?

(b) The total financial resources required to achieve the goals and objectives (that is, to achieve the applicant's proposed service delivery plan) of the new program or service. Supply all budget documents submitted to HRSA and any budget estimates that were prepared subsequent to the HRSA submission. Explain in detail the differences between HRSA and Medicaid submissions. If the change in scope of service is not reviewable by HRSA, include a statement to that effect.

(c) The number of proposed unduplicated patients and encounters at full operational capacity (Change of Scope Form 2, Annualized Encounters).

(d) One-time minor capital needs.

D. MEDICAID CHANGE IN SCOPE OF SERVICE REPORTING FORMS

The Medicaid Change in Scope of Service Reporting Forms must be completed whenever a change in scope of service (as defined in the Medicaid regulations) occurs. The initial submission must include separate forms for each year of the phase-in period in which the change in scope of service occurs. Please remember that all information reported on forms 1 through 5 are projected numbers, except when reporting actual information.

Instructions for Form Completion

Change in Scope of Service Certification Statement

Enter the FQHC name and FQHC provider number(s) of the site(s) affected by the change in scope of service.

Enter the reporting period of the data included in the application.

Circle the appropriate change in scope phase-in year.

Enter the name of the person who prepared the change in scope of service application.

Enter the signature of the officer of the FQHC and his or her title and date after the completion of the change in scope of service application.

Circle interim if based on projected data and circle actual if the phase-in year is complete.

Change in Scope of Service--Form 1, Annualized Budget

This form is used to record the annual costs related to the change in scope of service. The form should be used for each year from the beginning of the change in scope of service until the change in scope of service is fully phased in. Expense information must include further detail, as described below. In addition, if there are budget items for which costs are shared with other programs, the basis for allocation of costs between programs must be explained.

Enter the FQHC Name and FQHC provider number(s) of the site(s) affected by the change in scope of service. If the budget is based on projected data, circle interim budget and if the budget is based on actual data following the completion of a phase-in year, circle actual budget.

Enter the reporting period of the data included in the application.

Circle the appropriate change in scope phase-in year.

Line A--Personnel: Enter the total personnel costs for all new staff to be employed as a result of the change in scope of service. Include any increase in costs for existing staff that will be employed in the change in scope of service.

Line B--Fringe Benefits: Itemize the components that comprise the fringe benefit rate (for example, Health insurance, FICA, SUTA, life insurance, retirement plan). For any increase over the prior year rate, provide an explanation.

Line C--Equipment: Only major (with cost over $ 5,000 per unit) equipment items need to be itemized. Items costing less than $ 5,000 should be aggregated with a brief explanation.

Line D--Supplies: Categorize supplies according to type--medical, lab, pharmacy and office. Explain how the amounts were developed (for example, medical supplies were based on 20,000 encounters at $ 2.00 per encounter to arrive at the $ 40,000 appearing in the budget).

Line E--Travel: Itemize travel costs according to traveler type (Executive Director, Project Director, Board, provider for continuing medical education (CME), etc.) and explain how the amounts were developed. It is not necessary to itemize each trip or the costs associated with each trip. (Example: Physician CME 12 trips at $ 1,200 each)

Line F--Contractual: Categorize substantive programmatic or administrative contract costs according to type (for example, medical referral, lab referral, management consultant) under two headings--Patient care and non-patient care by costs.

Line G--Alteration and Renovation (A & R): Describe all A & R in progress.

Line H--Other: Itemize all costs in this category and explain in sufficient detail. Add additional lines, if necessary. In most cases, consultant costs for technical assistance, legal fees, rent, utilities, insurance, dues, subscriptions, and audit related costs would fall under this category.

Line I--Total: Sum the costs from lines A through H.

Change in Scope of Service--Form 2, Annualized Encounters

This form is used to record the annual encounters related to the change in scope of service. The form should be used for each year from the beginning of the change in scope of service until the change in scope of service is fully phased in.

Enter the FQHC name and FQHC provider number(s) of the site(s) affected by the change in scope of service.

Enter the reporting period of the data included in the application.

Circle the appropriate change in scope phase-in year.

Circle interim if based on projected data and circle actual if the phase-in year is complete.

Lines 1-21--Number of Medicaid Encounters: For the reporting period, enter the number of Medicaid encounters in column 2 relating to the category listed in column 1 on each line.

Lines 1-21--Total Encounters: For the reporting period, enter the total encounters in column 3 relating to the category listed in column 1 on each line (include Medicaid encounters in the total reported in column 3).

Line 22--Total Encounters: Sum the encounters from lines 1 through 21 in column 2 and column 3.

Line 23--Number of Unduplicated Patients by Year: Enter the number of unduplicated Medicaid patients served during the reporting period in column 2. Enter the total number of unduplicated Medicaid patients served during the reporting period in column 3.

Change in Scope of Service--Form 3, Annualized Visits

This form is used to record the number of visits related to the change in scope of service. The form should be used for each year from the beginning of the change in scope of service until the change in scope of service is fully phased in. (The data in this form is a copy of the data in form 3 of the BPHC Policy Information Notice 2001-18.)

Enter the FQHC name and FQHC provider number(s) of the site(s) affected by the change in scope of service.

Enter the reporting period of the data included in the application.

Circle the appropriate change in scope phase-in year.

Circle interim if based on projected data and circle actual if the phase-in year is complete.

Lines 1-13--Visits: Enter the number of visits relating to the payor category listed on each line.

Line 14--Grand Total: Sum the visits entered on lines 4, 7, 8, 9, 10, 11, 12 and 13.

Change in Scope of Service--Forms 4-A and 4-B, Personnel Costs

These forms are used to record all new or existing staff costs associated with the change in scope of service. These forms should be used for each year from the beginning of the change in scope of service until the change of scope is fully phased in.

Enter the FQHC name and FQHC provider number(s) of the site(s) affected by the change in scope of service.

Enter the reporting period of the data included in the application.

Circle the appropriate change in scope phase-in year.

Circle interim if based on projected data and circle actual if the phase-in year is complete.

Lines 1-68, Compensation, Fringe Benefits and Other

Column 1--Enter compensation expenses for the change in scope of service corresponding to the appropriate cost center lines.

Column 2--Enter Fringe Benefit expenses for the change in scope of service corresponding to the appropriate cost center lines.

Column 3--Enter any personnel expenses of various cost centers that are not compensation or fringe benefits, that are related to the change in scope of service.

Column 4--The sum of columns 1, 2 and 3 for each line is entered here.

Line 15, Total--Sum lines 2 through 14.

Line 30, Total--Sum lines 17 through 22 plus lines 24 through 29.

Line 35, Total--Sum lines 31 through 34.

Line 36, Page Totals--Sum lines 15, 30 and 35.

Line 52, Total--Sum lines 38 through 51.

Line 67, Total Administrative Costs--Sum lines 54 through 66.

Line 68, Page Totals--Sum lines 52 and 67.

Change in Scope of Service--Form 4-C, Physician Detail

This form is to record Physician data associated with the change in scope of service.

Enter the FQHC name and FQHC provider number(s) of the site(s) affected by the change in scope of service.

Enter the reporting period of the data included in the application.

Circle the appropriate change in scope phase-in year.

Circle interim if based on projected data and circle actual if the phase-in year is complete.

Column 1--Enter the date which the physician entered employment with the FQHC.

Column 2--If the physician's employment terminated during the change in scope period, enter the date.

Column 3--Enter the physician's Medicaid Provider Number.

Column 4--Enter the number of encounters performed by the physician corresponding to the change in scope of service.

Column 5--Enter the amount of gross compensation, including fringe benefits paid to the physician.

Column 6--Enter the number of hours for which the physician was compensated. Employment contracts and time records must be maintained for audit purposes.

Line 25, Total--Sum lines 1 through 24.

Change in Scope of Service--Form 4-D, Nursing Detail

This form is used to record Nurse Practitioner and Nurse Midwife data associated with the change in scope of service.

Enter the FQHC name and FQHC provider number(s) of the site(s) affected by the change in scope of service.

Enter the reporting period of the data included in the application.

Circle the appropriate change in scope phase-in year.

Circle interim if based on projected data and circle actual if the phase-in year is complete.

Column 1--Enter the date which the CNP/CNM entered employment with the FQHC.

Column 2--If the CNP/CNM'S employment terminated during the change in scope period, enter the date.

Column 3--Enter the CNP/CNM's License and/or Qualification.

Column 4--Enter the number of encounters performed by the CNP/CNM associated with the change in scope of service.

Column 5--Enter the amount of gross compensation, including fringe benefits, paid to the CNP/CNM.

Column 6--Enter the number of hours for which the CNP/CNM was compensated. Employment contracts and time records must be maintained for audit purposes.

Line 10, Total Nurse Practitioners--Sum lines 1 through 9.

Line 25, Total Nurse Mid-Wives--Sum lines 12 through 24.

Change in Scope of Service--Form 4 E, Dental Detail

This form is used to record Dental and Dental Hygienist data associated with the change in scope of service.

Enter the FQHC name and FQHC provider number(s) of the site(s) affected by the change in scope of service.

Enter the reporting period of the data included in the application.

Circle the appropriate change in scope phase-in year.

Circle interim if based on projected data and circle actual if the phase-in year is complete.

Column 1--Enter the date which the Dentist/Dental Hygienist entered employment with FQHC.

Column 2--If the Dentist/Dental Hygienist employment terminated during the change in scope period, enter the date.

Column 3--Enter the Dentist/Dental Hygienist License and/or Qualification.

Column 4--Enter the number of encounters performed by the Dentist/Dental Hygienist associated with the change in scope of service.

Column 5--Enter the amount of gross compensation, including fringe benefits, paid to the Dentist/Dental Hygienist.

Column 6--Enter the number of hours for which the Dentist/Dental Hygienist was compensated. Employment contracts and time records must be maintained for audit purposes.

Line 10, Total Dentists--Sum lines 1 through 9.

Line 25, Total Dental Hygienists--Sum lines 12 through 24.

Change in Scope of Service--Form 5 Current Services Provided

Form 5 is used to record the current services provided on-site or by referral, for the site where the change in scope of service will occur. A separate form must be completed for each site where the change in scope of service will occur.

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N.J. Admin. Code 10:66-4 app D

New Rule, R.2004 d.208, effective 6/7/2004.
See: 36 New Jersey Register 324(a), 36 New Jersey Register 2834(a).