Essential Community Provider Application for …

1 MANAGED CARE SYSTEMS SECTION Essential Community Providers Designation Box 64975, St. Paul, Minnesota 55164-0975 Telephone: (651) 201-5173 Essential Community Provider Application for Designation Pursuant to Minnesota Statutes, Section and Minnesota Rules, Chapter 4688 General Information Minnesota Statutes authorizes the commissioner of health to designate providers as Essential Community providers. An applicant must be a non-profit, tax-exempt entity; a local government unit; certain hospital districts; an Indian tribal government, health service, or service unit; Community health board; or a qualified sole Community hospital. All applicants must have demonstrated ability to integrate applicable supportive and stabilizing services with medical care for uninsured persons, high-risk and special needs populations, and underserved and other special needs populations. In addition, they must have a plan to identify the need for supportive and stabilizing services and to enable clients to access these services.

2 Application Instructions 1. Provide all requested information. Be as complete as possible. If a section does not apply to you, mark it Not Applicable and explain why. If you need additional space to answer a question, use a separate page(s) and clearly indicate to which section it applies. 2. You are responsible for identifying current requirements of law or rules relating to Essential Community providers that may not be indicated in this Application form. Minnesota Statutes and Minnesota Rules Chapter 4688 can be viewed through: 3. You must include a non-refundable Application fee of $60, payable to: Treasurer, State of Minnesota with this Application . 4. Submit the completed Application to: Minnesota Department of Health Managed Care Systems Section Box 64882 Saint Paul MN 55164-0882 If you have questions about how to complete this Application , c ontact Anne Kukowski at (651) 201-5173, or by email at 1 Application for Essential Community Provider Designation PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK SECTION A Name of Organization Street Address (no box address) Mailing Address (if Different than Street Address) City State Zip County Organization Website Organization Telephone Contact Person/Title Contact Email Address Contact Telephone This is a New Application Re-designation Yes No I have included the $60 Application fee.

3 Date Application Submitted SECTION B (See Minnesota Statutes, Section , subd. 1(a)) Are you applying as a(n): local government unit Indian tribal government Indian health service unit tax-exempt non-profit entity Community health board former state hospital rural sole Community hospital licensed birth center district hospital hospital and affiliated clinics predominately serving patients under the age of 21 If you are applying as a tax-exempt non-profit entity, you must attach the following supporting documentation: 1. Evidence of Minnesota Statutes Chapter 317A non-profit status. 2. Evidence of Internal Revenue Code 501(c) (3) tax-exempt status. 3. A copy of your current sliding fee schedule. (Minnesota Rules, , B(2); subp. 5) 4. Evidence that you do not restrict access or services because of your clients financial limitations. 2 If you are applying as a hospital and affiliated specialty clinics predominately serving patients under the age of 21, you must attach the following supporting documentation: 1.

4 Evidence of providing intensive specialty pediatric services that are routinely provided in fewer than five hospitals in Minnesota; and 2. Evidence of serving children from at least half of the counties in Minnesota; and 3. Evidence of primarily serving patients under the age of 21. If you are applying as a (rural) sole Community hospital, you must attach the following supporting documentation: 1. Evidence of eligibility to be classified as a sole Community hospital according to the Code of Federal regulations, title 42, section , or is located in a Community with a population of less than 5,000 and located more than 25 miles from a like hospital currently providing acute short-term services; and 2. Evidence of a net operating income losses in two of the previous three most consecutive hospital fiscal years for which audited financial information is available; and 3. Evidence of consisting of 40 or fewer licensed beds. SECTION C (See Minnesota Statutes, Section , subd.)

5 1 (c)) Indicate the category(s) of care and or service(s) provided at the facility listed in section A: Mental health Chemical dependency Primary care Medical services dental Rehabilitative (PT OT Speech) Family planning Home health care Birthing (birthing centers only) Are services restricted to students? Yes No On a separate sheet of paper, identify satellite clinics to be included under the ECP designation. Each clinic included in the ECP designation must meet all ECP requirements. For each satellite, list the clinic name, address, telephone number, and county, and identify the category(s) of care and or service(s) provided, and whether services are restricted to students. See Appendix A for a sample table format. SECTION D 1. Provide an overview of your agency. Include a copy of your organizational chart, if such a chart exists. 2. Provide Current Procedural Terminology (CPT) codes for all services provided.

6 There must be a descriptor for each identified CPT code. (See Minnesota Statutes, Section , subd. 1 (c); Minnesota Rules, , C) 3 SECTION E (See Minnesota Rules, , D; subp. 2) Please attach the required information to this Application : 1. Evidence you have sufficient personnel and facilities to provide timely medical care to your clients, consistent with Community norms. Include a list of the total numbers, and all types of health care professionals you have available to provide services to your clients. 2. A copy of your appointment scheduling policy and procedures. Provide data on average waiting times. Average waiting times must fall within Community norms. 3. An explanation as to how you monitor appointment scheduling and waiting times, and how you take corrective actions when indicated. SECTION F (See Rule , item E; and definitions on page 1 of this Application ) Please provide numbers requested in the table below, using the following definitions: Uninsured means clients who have no insurance.

7 Public Insurance means Medicare, Medicaid, MinnesotaCare, Minnesota Health Care Programs, etc. High-risk/special needs includes: People with chronic health or medical conditions People with persistent serious mental health issues People who are chemically dependent People with high-cost preexisting conditions Adolescents Pregnant women Elderly An underserved population means a group facing economic, cultural or linguistic barriers to health care, including people who: Are Homeless Are Low-income From racial or ethnic communities Have limited or no English language proficiency Are not cis-gender and/or not heterosexual An underserved area means a geographic area with a shortage of primary care health services. For information about medically underserved areas and populations, see Number of Clients for the Preceding Calendar Year Total Uninsured Have Public Insurance Have Commercial Insurance Receive Discount / Pay Sliding Fee High risk/special needs Belong to an underserved population Live in an underserved area Note: Columns labeled Uninsured, Have Public Insurance, and Have Commercial Insurance should sum to Total.

8 Other columns are independent and a client may be counted in more than one of them. Total number of clients projected for the current calendar year _____. 4 SECTION G (See Minnesota Statutes, Section , subd. 1 (d); Minnesota Rules, , F; subp. 3) An ECP must provide or coordinate the provision of supportive and stabilizing services appropriate to the population and geographic area served. 1. On a separate piece of paper, list supporting and stabilizing services you provide. Include: how you assess the need for these services; how these services are made available to clients; how clients access these services; and how many clients use these services. 2. Complete the table below. Check provided and/or coordinated or not applicable, and provide or estimate the number of unique clients who used each service. Service Provided Coordinated Not Applicable # of Clients who used these services in past year Transportation services Child care services Linguistic Services Culturally sensitive and competent services Other services If you indicate that a service listed in the table is not applicable, please explain why it is not appropriate for the area or population served.

9 3. How do you provide pre-service and in-service training for all professional and support staff on cultural awareness and health issues affecting high-risk and special-needs clients? State when and where training has taken place. Attach training curricula to the Application . Alternatively, show that, for each site, you have professional staff familiar with the cultural background of clients. SECTION H 1. Provide any recent client satisfaction survey; and a summary of the results. 2. How many complaints or grievances did you receive in the last year? What was the nature of complaints or grievances received? How many were substantiated? I hereby swear that information submitted with this Application is true to the best of my knowledge. _____ Signature of officer Date _____ Signer and Title (typed or printed) Name of Facility 5 Appendix A.

10 Sample table for listing satellite locations NAME STREET City Zip Code Telephone County Mental Health Services Chemical Dependency Services Primary Care Services Medical Services dental Care Physical Rehab Services Family Planning Home Care Services Indian Health Provider Serving Students Only