39E Program Specific Form Instructions Edits

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

Program-Specific Forms Instructions

Program-Specific Forms must be completed electronically in HRSA EHB All.s forms are required, except .SAC Technical Assistance website HYPERLINK "http://bphc.hrsa.gov/programopportunities/fundingopportunities/SAC/index.html" Form 5C: Other Activities/Locations HYPERLINK "https://bphc.hrsa.gov/program-opportunities/funding-opportunities/sac" 

• https://bhw.hrsa.gov/shortage-designation HYPERLINK "https://bhw.hrsa.gov/shortage-designation" sdb@hrsa.gov

• http://www.hrsa.gov/ruralhealth/policy/definition_of_rural.html

 HYPERLINK "https://bphc.hrsa.gov/datareporting/reporting/index.html" for detailed information):

• A visit is a face-to-face contact between a patient and a licensed or credentialed provider who exercises independent, professional judgment in providing services. To be included as a visit, services must be paid for by your organization (, Columns I and/or II) Form 5A: Services Providedand documented in a written or electronic form in a system that permits ready retrieval of current data for the patient.

• A patient is an individual who had at least one visit in 201 (8current data) or is projected to have at least one visit in 202 1(projected data).

• Since a patient must have at least one documented visit, the number of patients cannot exceed the number of visits.

• Report aggregate data for all service sites in the proposed project.

• If

• you are a new or competing supplement applicant, report calendar year baseline values for services your organization is currently providing in the proposed service area. If your organization is not currently operational in the proposed service area, report baseline values as zero.

Unduplicated Patients and Visits by Population Type:

The population types in this section do NOT refer only to the requested funding categories in Section A of the SF-424A: Budget Information form. For example, if you are applying for only CHC funding (General Underserved Community), you may still have patients/visits reported in the other population type categories. All patients/visits that do not fall within the Migratory and Seasonal Agricultural Workers and Families, Residents of Public Housing, or the People Experiencing Homelessness categories must be included in the General Underserved Community category.

1. Project the number of unduplicated patients to be served in 202 (January 1 through1 December 31, 202). 1 This value will pre-populate in the corresponding cell within the table below.

HRSA will use the number of unduplicated patients projected to be served in ), funding for the service area may be reduced when the service area is next competed through SAC (assuming a 3-year project period).1 (the patient projection from this application, plus other patient projections from funded supplemental applications for which the projections can be monitored in 2021 in 202target Patient Target. If a health center is unable to meet the total unduplicated patient SAAT HYPERLINK "https://bphc.hrsa.gov/sac/" 

Compliance Manual HYPERLINK "https://www.bphc.hrsa.gov/programrequirements/compliancemanual/introduction.html" 

Operational Site Visit HYPERLINK "https://www.bphc.hrsa.gov/programrequirements/svprotocol.html" 

• UDS Manual

 HYPERLINK "https://bphc.hrsa.gov/datareporting/reporting/index.html" All patient service revenue is reported in this section of the form.

Patient service revenue includes income earned from Medicaid and Medicare rate settlements and wrap reconciliations that are designed to make up the difference between the approved FQHC rate and the interim amounts received. It includes risk pool and other incentive income as well as primary care case management fees. ¹.for help with the application processontact your PCA c , Medicaid and Medicarerom reimbursement rate f costIf you do not have an FQHC

Only include patient service revenue associated with sites and services proposed in this application.

Patients by Primary Medical Insurance - Column (a):  The projected number of unduplicated patients classified by payer based upon the patient’s primary medical insurance (payer billed first). The patients are classified in the same way as in the UDS Manual HYPERLINK "https://bphc.hrsa.gov/datareporting/reporting/index.html" , Table 4, lines 7 – 12. Examples for determining where to count patients include:

• A crossover patient with Medicare and Medicaid coverage is to be classified as a Medicare patient on line 2.

• A Medicaid patient with no dental coverage who is only seen for dental services is to be classified as a Medicaid patient on line 1 with a self-pay visit on line 5.

Billable Visits – Column (b): Includes all billable/reimbursable visits.² The value is typically based on assumptions about the amount of available clinician time, clinician productivity (visits per unit of time), and mix of billable visits by payer. Do not include billable services related to laboratory, pharmacy, imaging, and other ancillary services in this column. (See Ancillary Instructions HYPERLINK \l "Ancillary_Instructions" below.) Note other significant exclusions or additions in the Comment/Explanatory Notes box at the bottom of the form.

Note: The patient service income budget is primarily based on income per visit estimates. However, some forms of patient service income do not generate reportable visits, such as income from laboratory or pharmacy services, capitated-managed care, performance incentives, wrap payments, and cost report settlements. Based on historical experience, you may choose to include some or all of this income in the income per visit assumption. You may also choose to separately budget for some or all of these sources of patient service income.

Income per Visit – Column (c): Calculated by dividing projected income in Column (d) by billable visits in Column (b).

Projected Income – Column (d): Projected accrued net revenue, including an allowance for bad debt, from all patient services for each pay grouping. Pharmacy income may be estimated using historical data to determine the number of prescriptions per medical visit and the average income per prescription. All separate projections of income are consolidated and reported here.

Prior FY Income – Column (e): The income data from the health center’s most recent fiscal year, which will be either interim statement data or audit data, when available.

Alternative Instructions for Capitated Managed Care:

Health centers may use their own methods for budgeting patient service income other than those noted above, but must report the consolidated result in the Projected Income Column (d), along with the related data requested in Columns (a) through (e). Income for each service may be estimated by multiplying the projected visits by assumed income per visit. For example, capitated managed care income may be based on member-month enrollment projections and estimated capitation rates for each plan, grouped by payer and added to the projected income. Enter the estimated visits associated with these managed care plans in Column (b).

Payer Categories (Lines 1 – 5): The five payer categories (Medicaid, Medicare, Other Public, Private, and Self-Pay) reflect the five payer groupings in UDS. The UDS Manual HYPERLINK "https://bphc.hrsa.gov/datareporting/reporting/index.html" includes definitions for each payer category.

Visits are reported on the line of the primary payer, which is the payer billed first. When a single visit involves more than one payer, attribute each portion of the visit income to the payer group from which it is earned. In cases where there are deductibles and co-payments to be paid by the patient, report that income on the self-pay line. If the co-payment is to be paid by another payer, report that income on the other payer’s line. It is acceptable if you cannot accurately associate the income to secondary and subsequent sources.

Ancillary Instructions: All service income is to be classified by payer, including pharmacy and other ancillary service revenue. If you do not normally classify the projected ancillary or other service revenue by payer category, allocate the projected income by payer group using a reasonable method, such as the proportion of medical visits or charges. The method used should be noted in the Comments/Explanatory Notes section at the bottom of the form.

Medicaid (Line 1): Income from FQHC cost reimbursement; capitated managed care; fee-for-service managed care; Early Periodic Screening, Diagnosis, and Treatment (EPSDT); Children’s Health Insurance Program (CHIP); and other reimbursement arrangements administered either directly by the state agency or by a fiscal intermediary. It includes all projected income from managed care capitation, settlements from FQHC cost reimbursement reconciliations, wrap-around payments, performance incentives, pharmaceutical reimbursements, and primary care case management income.

Medicare (Line 2): Income from the FQHC cost reimbursement, capitated managed care, fee-for-service managed care, Medicare Advantage plans, and other reimbursement arrangements administered either directly by Medicare or by a fiscal intermediary. It includes all projected income from managed care capitation, settlements from the FQHC cost reimbursement reconciliations, risk pool distributions, performance incentives, pharmaceutical reimbursements, and case management fee income.

Other Public (Line 3): Income not reported elsewhere from federal, state, or local government programs earned for providing services or pharmaceuticals that is unearned or based upon meeting the plan’s eligibility criteria. A CHIP operated independently from the Medicaid program is an example of other public insurance. Other Public income also includes income from categorical grant programs when the grant income is earned by providing services (e.g., Centers for Disease Control and Prevention’s (CDC) National Breast and Cervical Cancer Early Detection Program).

Private (Line 4): Income earned from or paid for by private insurance plans, managed care plans, and other private contracts for services or pharmaceuticals. This includes plans such as Blue Cross and Blue Shield, commercial insurance, managed care plans, self-insured employer plans, group contracts with unions and employers, service contracts with employers, and Veterans Health Administration Community Based Outpatient Clinic (CBOC) contracts. Income from health benefit plans that are earned by government employees, veterans, retirees, and dependents, such as TRICARE, the federal employee health benefits program, state employee health insurance benefit programs, teacher health insurance, and similar plans are to be classified as private insurance.

Self-Pay (Line 5): Income from patients, including full-pay, self-pay, and sliding fee patients, as well as the portion of the visit income for which an insured patient is personally responsible.

Total (Line 6): Sum of lines 1-5.

Part 2: Other Income – Other Federal, State, Local, and Other Income

This section includes all income other than the patient service revenue shown in Part 1 (exclusive of this Health Center Program funding request). It includes other federal, state, local, and other income. It is income that is earned but not directly tied to visits, procedures, or other specific services. It includes income from services provided to non-health center patients (see examples below). This would include income from in-house retail pharmacy sales to individuals who are not patients of the health center. Income is to be classified based on the source .

Other Federal (Line 7): Income from direct federal funds, where your organization is the recipient of an NoA directly from a federal agency. It includes funds from federal sources such as the CDC, Housing and Urban Development (HUD), Centers for Medicare & Medicaid Services (CMS), and Department of Health and Human Service funding under the Ryan White HIV/AIDS Program Part C, School-Based Health Center Capital grants, and others. The CMS EHR incentive program income is reported here to be consistent with the UDS Manual HYPERLINK "https://bphc.hrsa.gov/datareporting/reporting/index.html" . Exclude this Health Center Program funding request.

State Government (Line 8): Income from state government funding, contracts, and programs, including uncompensated care funding; state indigent care income; emergency preparedness funding; mortgage assistance; capital improvement funding; school health funding; Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); immunization funding; and similar awards.

Local Government (Line 9): Income from local government grants, contracts, and programs, including local indigent care income, community development block grants, capital improvement project funding, federal funding awarded through intermediaries, and similar awards. For example, include: (1) income earned under a contract with the local Department of Health to provide services to the Department’s patients, and (2) Ryan White Part A that are awarded through municipalities.

Private Grants/Contracts (Line 10): Income from private sources, such as foundations, non-profits, hospitals, nursing homes, drug companies, employers, other health centers, and similar entities. For example, if you e operata pharmacy in part for your own patients and in part as a contractor to another health center, report the pharmacy income for your own patients in Part 1 under the appropriate payer categories and the income from the contracted health center on this line.

Contributions (Line 11): Income from private entities and individual donors that may be the result of fundraising.

Other (Line 12): Incidental income not reported elsewhere, including items such as interest income, patient record fees, vending machine income, dues, and rental income. Applicants typically have at least some “other” income to report on Line 12.

Applicant (Retained Earnings) (Line 13): The amount of funds needed from your retained earnings or reserves in order to achieve a breakeven budget. Explain in the Comments/Explanatory notes section why your funds (retained earnings) are needed for this purpose. Amounts from non-federal sources, combined with this Health Center Program funding request, should typically be adequate to support operations.

Total Other (Line 14): The sum of lines 7 – 13.

Total Non-Federal (Line 15): The sum of Lines 6 and 14 (the total income aside from this Health Center Program ).funding request

Note: In-kind donations are not included on Form 3. You may discuss in-kind donations in the SUPPORT REQUESTED section of the Project Narrative. Additionally, such donations may be included on the SF-424A (Section A: Budget Summary—Non-Federal Resources under New or Revised Budget).

Form 4: Community Characteristics

Report current service area and target population data. Data on race and/or ethnicity collected on this form will not be used as an awarding factor. If you compile data from multiple data sources, the total numbers may vary across sources. If this is the case, make adjustments as needed to ensure that the total numbers for the first four sections of this form match. Adjustments must be explained in the NEED section of the Project Narrative.

Service area data must be specific to the proposed project and include the total number of individuals for each characteristic (percentages will automatically calculate in HRSA EHBs). If information for the service area is not available, extrapolate data from the U.S. Census Bureau, local planning agencies, health departments, and other local, state, and national data sources. Estimates are acceptable.

Target population data are most often a subset of service area population data. Report the number of individuals for each characteristic (percentages will automatically calculate in HRSA EHBs). Estimates are acceptable. Patient data should not be used to report target population data since patients are typically a subset of this number.

If the target population includes a large number of transient individuals that are not included in the data set used for service area population data (e.g., census data), adjust the service area population numbers accordingly to ensure that the target population numbers are always less than or equal to the service area population numbers.

Note: The total numbers for the first four sections of this form must match.

Guidelines for Reporting Race

• Classify all individuals in one of the racial categories, including individuals who also consider themselves Hispanic or Latino. If the data source does not separately classify Hispanic or Latino individuals by race, report them as Unreported/Declined to Report.

• Utilize the following race definitions:

• Asian – Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Indonesia, Thailand, and Vietnam.

• Native Hawaiian – Persons having origins in any of the original peoples of Hawaii.

• Other Pacific Islanders – Persons having origins in any of the original peoples of Guam, Samoa, Tonga, Palau, Truk, Yap, Saipan, , Pohnpei, Ebeye, Kosraeor other Pacific Islands in Micronesia, Melanesia, or Polynesia.

• American Indian/Alaska Native – Persons having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

• More Than One Race – Persons who are choosing two or more races.

Guidelines for Reporting Hispanic or Latino Ethnicity

• If ethnicity is unknown, report individuals as Unreported/Declined to Report.

• Utilize the following ethnicity definition: Hispanic or Latino – Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Guidelines for Reporting Special Populations and Select Population Characteristics

The Special Populations section of Form 4 does not have a row for total numbers. Individuals that represent multiple special population categories should be counted in all applicable categories.

Forms 5A, 5B, and 5C

General Notes

• Competing continuation applicants: These forms will be pre-populated and cannot be modified to ensure that they reflect the current scope of project. Changes in services, sites, and other activities/locations require prior approval through a Change in Scope request submitted in HRSA EHBs. If the pre-populated data do not reflect recently approved scope changes, click the Refresh from Scope button in HRSA EHBs to display the latest scope of project.

Note: for Box 2 Continuation In order for forms to accurately pre-populate, you must correctly complete the SF-424 in Grants.gov by selecting and providing the grant number for Box 4. application access.sFailure to apply in this manner may result in delayed HRSA EHB

• New or competing supplement applicants: Complete these forms based only on the scope of project included in this application for the proposed service area.

• If the application is funded, only the services, sites, and other activities/locations listed on these forms will be in the approved scope of project, regardless of what is described elsewhere in the application.

• Refer to the Scope of Project documents and resources for details pertaining to defining and changing scope (i.e., services, sites, service area zip codes, target population).

Form 5A: Services Provided

Identify how services will be provided (i.e., direct by health center, formal written contract (health center pays for service), formal written referral arrangement).

• You must provide all required services without regard to ability to pay and on a sliding fee discount schedule.

• Additional services are not required. However, in order to be considered in-scope services, additional services be must be listed on this form and provided without regard for ability to pay and on a sliding fee discount schedule.

For more information, refer to Only one form is required regardless of the number of sites proposed. : Required and Additional Health Services of the Compliance Manual. Chapter 4 HYPERLINK "https://bphc.hrsa.gov/programrequirements/compliancemanual/chapter-4.html" 

Column DescriptorsForm 5A HYPERLINK "https://bphc.hrsa.gov/sites/default/files/bphc/programrequirements/scope/form5acolumndescriptors.pdf" Form 5A Service Descriptors HYPERLINK "https://bphc.hrsa.gov/about/requirements/scope/form5aservicedescriptors.pdf" 

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SAAT HYPERLINK "https://bphc.hrsa.gov/sac/" SAAT HYPERLINK "https://bphc.hrsa.gov/sac/" ⁵

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2. ⁸

Uniform Guidance 2 CFR part 200 as codified by HHS at 45 CFR part 75

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Forms 1A: General Information Worksheet5B: Service Sites

HYPERLINK "https://bphc.hrsa.gov/sac/"



 HYPERLINK "https://bphc.hrsa.gov/sac/" The percentage of patients to be served in 2021 will auto-calculate. Applications with an auto-calculated percentage below 75 percent will be deemed ineligible.

Federal Request for Health Center Program Funding

To ensure eligibility, the total Health Center Program funding request must not exceed the Total Funding available in the SAAT HYPERLINK "https://bphc.hrsa.gov/sac/" for the proposed service area. Additionally, ensure that the funding requested for each population aligns with the values in the SAAT HYPERLINK "https://bphc.hrsa.gov/sac/" If the unduplicated patient projection on Form 1A General Information Worksheet is less than 95 percent of the SAAT HYPERLINK "https://bphc.hrsa.gov/sac/" Patient Target, ensure the annual Health Center Program funding request is adjusted based on the auto-calculated percentage of patients to be served in calendar year 2021 from the Patient Projection section of this form. If the total Health Center Program funding request is reduced, funding requested for each targeted population (e.g., CHC, MHC) must maintain the same distribution as in the .SAAT HYPERLINK "https://bphc.hrsa.gov/sac/" 

paperwork@hrsa.gov HYPERLINK "https://sharepoint.hrsa.gov/sites/bphc/oppd/ED1/OMB%20Forms%20Approval%202020/paperwork@hrsa.gov" 42 U.S.C. 254b HYPERLINK "http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim"

1 For a listing of HRSA-supported PCAs, refer to HRSA’s Strategic Partnerships website.

2 These visits will correspond closely with the visits reported on the UDS ManualUDS Manual Table 5, excluding enabling service visits.

3

4

5Form 5B: Service SitesSAATPolicy Information Notice 2007-09

6 Scope of Project

7PIN 2014-01Chapter 20Compliance Manual

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9HHS Grants Policy Statement

1045 CFR 75 Subpart E: Cost Principles

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