As stated above, services provided by primary care clinicians as part of their ordinary scope of practice are not considered specialty services; thus, this PIN is not directly applicable to requests to add such services to the Federal section 330 scope of project.

Although prior approval is still necessary, in general, the addition of services listed as examples of “additional health services” in section 330(b)(2) of the PHS Act will be considered appropriate for inclusion within the health center’s Federal scope of project.  These services include:  behavioral and mental health and substance abuse services;¹⁸ recuperative care services; environmental health services; and occupation-related health services for migratory and seasonal agricultural workers. 

When reviewing a request to add specialty services to the Federal scope of project, HRSA will evaluate the request using the factors listed below.  These factors were developed taking into consideration HRSA’s goal of supporting the extension of necessary health services to current health center patients in support of required primary health services while ensuring that health centers continue to (1) meet the current statutory, regulatory, and policy requirements of the Health Center Program and (2) comply with DHHS grants regulations and policy.

Section 330 authorizes the provision of “additional” health services “as may be appropriate for particular centers” when those services are “necessary for the adequate support of the [required] primary health services.”¹⁹  Therefore, when requesting a change in scope to add a specialty service to the Federal scope of project, a health center must demonstrate how the new service will support the provision of the required primary care services provided by the health center.  In other words, the health center must show that the proposed services function as a logical extension of the required primary care services already provided by the health center and/or that the proposed services complement the required primary health care services.  Examples of services that may be a complementary extension of primary health care include: 

• pulmonary consultations, and/or examinations, where the health center serves a substantial number of patients with asthma, COPD, Black Lung, or tuberculosis;
• cardiology screenings and diagnoses, where the health center serves a substantial number of patients at risk for heart disease or high blood pressure;
• minor podiatry outpatient procedures or examinations, where the health center serves a population with a high prevalence of diabetes;
• psychiatric consultations, examinations and differential diagnoses, where the health center serves a substantial number of patients with mental health and/or substance abuse diagnoses;
• periodontic services, where the health center serves a significant population of children with poor oral health;
• colonoscopies; and
• appropriate oncological care of health center patients with cancer.

 

B. Demonstrated Need for the Proposed Specialty Service

Section 330 authorizes the provision of non-required “additional” health services when appropriate to meet the needs of the target population.  Therefore, when requesting a change in scope to add a specialty service to the Federal scope of project, a health center must demonstrate and document the target population’s need for the proposed service.  Unmet need should be described both in narrative format and with data.

In addition, when proposing the addition of a specialty service, the health center must demonstrate its ability to maintain the level and quality of the required primary health services currently provided to the target population (see section V above).  

C. Funding/Budget/Financial Risk

Any requested change in the Federal scope of project must be fully accomplished with no additional section 330 grant support.  In assessing the financial impact of adding a service, a health center should consider whether the service will be considered a “FQHC service” and, therefore, be eligible for enhanced FQHC Medicaid/Medicare reimbursement.  In general, the site or service to be added must be able to generate adequate revenue to cover all expenses, including overhead costs incurred by the health center in managing the site or service.  If additional Federal funds will be necessary to fully implement the change in Federal scope, the grantee should apply for competitive funding as appropriate, with the awareness that Federal grant dollars are limited.  And, as stated above, the provision of any additional service must not compromise the provision of required primary health care services.  In summary, when requesting a change in Federal scope to add a specialty service to the scope of project, a health center must demonstrate that adding the new service (1) will not jeopardize the health center’s overall financial stability and (2) will be accomplished with no additional section 330 grant funds. 

D. Location of the Service

In order to ensure that the proposed new service will be accessible to health center patients, and that the health center will be able to maintain appropriate control over service delivery, the service must be provided at an approved site (see definition above) within the Federal scope of project, at a new site that will be proximate to available FQHC services,²⁰ or at a location where in-scope services are provided but that does not meet the definition of a service site.  Therefore, when requesting a change in the Federal scope of project to add a specialty service, a health center must (1) describe the specific location of the proposed service and (2) demonstrate that the service will be provided at an approved health center site, a proposed new site proximate to available FQHC services or at a location where in-scope services are provided but that does not meet the definition of a service site.  In all cases, health centers must ensure that adequate and appropriate documentation has been secured to support and enable performance of the specialty services (e.g., translation and transportation services as needed).

If a specialty service is provided at a location that does not meet the definition of a service site, the health center must document the manner by which the referral will be made and managed and the process for facilitating appropriate follow-up care at the health center.  Additionally, health centers must ensure services are provided in culturally and linguistically appropriate manner based on the target population(s).  And finally, once a service is included in the approved scope of project, it must be available equally to all patients regardless of ability to pay and available through a sliding fee scale according to 42 C.F.R. 51c.303(f).  Specifically, the discounted fee schedule must provide a full discount to individuals and families with annual incomes at or below the poverty guidelines (only nominal fees that do not impede access to care may be charged) and for those with incomes between 100 percent and 200 percent of poverty, fees must be charged in accordance with a sliding discount policy based on family size and income.  No discounts may be provided to patients with incomes over 200 percent of the Federal poverty level.²¹

Additional Considerations

1. State Licensing:  Providers must be properly licensed, according to their State or territory’s laws, to be included within the health center’s Federal scope of project.  Approval of a request to add providers of new services to the Federal scope of project is contingent upon the health center’s demonstration that all providers associated with the new service meet the professional, State, and local qualifications necessary to provide that service.

2.Credentialing and Privileging:  All providers must be properly credentialed and privileged to perform the activities and procedures expected of them by the health center.  “Credentialing” is the process of assessing and confirming the qualifications of a licensed or certified health care practitioner.  “Privileging” is the process of authorizing a licensed or certified health care practitioner’s specific scope of patient care services.  Privileging is performed in conjunction with an evaluation of an individual’s clinical qualifications and/or performance.  It is the responsibility of the health center to ensure that all credentialing and privileging of providers have been completed before including a service in the Federal scope of project.  Therefore, a health center requesting the addition of a specialty service to the Federal scope of project must demonstrate that the credentialing and privileging requirements have been met.²²

3. Potential Staffing Arrangements/Corporate Structure:  Health centers utilize a variety of mechanisms for provider staffing.  For instance, health centers may directly employ or contract with providers and/or have arrangements with other organizations for clinical staffing of the health center.  Health centers are encouraged to carefully consider the benefits and risks associated with various staffing arrangements because each impacts health center costs and operations differently.  When evaluating change in Federal scope requests, HRSA will examine the proposed staffing arrangement as part of a review of the impact of the proposed change on the total organization (e.g., whether the arrangement necessitates an affiliation agreement).  Therefore, health centers requesting the addition of a specialty service to the Federal section 330 scope of project must provide a clear and comprehensive description of the relevant staffing arrangements and describe any potential impact on the overall organization.