MockCONApplicationform-BLAW6500.docx

State of Tennessee Health Services and Development Agency Andrew Jackson Building, 9th Floor, 502 Deaderick Street, Nashville, TN 37243 www.tn.gov/hsda Phone: 615-741-2364 Email: hsda.staff@tn.gov

CERTIFICATE OF NEED APPLICATION

1A. Name of Facility, Agency, or Institution

Name
Street or Route					County
City			State		Zip
Website Address

Note: The facility’s name and address must be the name and address of the project and must be consistent with the Publication of Intent.

2A. Contact Person Available for Responses to Questions (Students – your name goes here).

Name					Title
Company Name				Email Address
Street or Route
City			State		Zip
Association with Owner				Phone Number

3A. Proof of Publication – N/A

Attach the full page of newspaper in which the notice of intent appeared with the mast and dateline intact or submit a publication affidavit from the newspaper that includes a copy of the publication as proof of the publication of the letter of intent. (Attachment 3A)

Date LOI was Submitted:

Date LOI was Published:

4A. Purpose of Review (Check appropriate box(es) – more than one response may apply)

Establish New Health Care Institution

Addition of a Specialty to an Ambulatory Surgical Treatment Center (ASTC)

Change in Bed Complement

Initiation of Health Care Service as Defined in §TCA 68-11-1607(3) Specify: _____

Relocation

Initiation of MRI Service

MRI Unit Increase

Satellite Emergency Department

Addition of ASTC Specialty

Initiation of Cardiac Catheterization

Addition of Therapeutic Catheterization

Establishment of a Non-Residential Substitution Based Opioid Treatment Center

Linear Accelerator Service

Positron Emission Tomography (PET) Service

Please answer all questions on letter size, white paper, clearly typed and spaced, single sided, in order and sequentially numbered. In answering, please type the question and the response. All questions must be answered. If an item does not apply, please indicate “N/A” (not applicable). Attach appropriate documentation as an Appendix at the end of the application and reference the applicable item Number on the attachment, i.e. Attachment 1A, 2A, etc. The last page of the application should be a completed signed and notarized affidavit.

5A. Type of Institution (Check all appropriate boxes – more than one response may apply)

Hospital (Specify):

Ambulatory Surgical Treatment Center (ASTC) – Multi-Specialty

Ambulatory Surgical Treatment Center (ASTC) – Single Specialty

Home Health

Hospice

Intellectual Disability Institutional Habilitation Facility (ICF/IID)

Nursing Home

Outpatient Diagnostic Center

Rehabilitation Facility

Residential Hospice

Nonresidential Substitution Based Treatment Center of Opiate Addiction

Other (Specify):

6A. Name of Owner of the Facility, Agency, or Institution – N/A

Name
Street or Route					Phone Number
City			State		Zip

EXECUTIVE SUMMARY

1E. Overview

Please provide an overview not to exceed ONE PAGE (for 1E only) in total explaining each item point below.

· Description: Address the establishment of a health care institution, initiation of health services, and/or bed complement changes.

RESPONSE:

· Ownership structure – N/A

· Service Area (Counties in which you expect most of the patients will reside). N/A

RESPONSE:

· Existing similar service providers in the county you propose to serve

RESPONSE:

· Project Cost — N/A

· Staffing – N/A

2E. Rationale for Approval

A Certificate of Need can only be granted when a project is necessary to provide needed health care in the area to be served, will provide health care that meets appropriate quality standards, and the effects attributed to competition or duplication would be positive for consumers

Provide a brief description not to exceed ONE PAGE (for 2E only) of how the project meets the criteria necessary for granting a CON using the data and information points provided in criteria sections that follow.

· Need

RESPONSE:

· Quality Standards

RESPONSE:

· Consumer Advantage

· Choice

· Improved access/availability to health care service(s)

· Affordability

RESPONSE:

3E. Consent Calendar Justification – N/A

Consent Calendar Requested (Attach rationale)

If Consent Calendar is requested, please attach the rationale for an expedited review in terms of Need, Quality Standards, and Consumer Advantage as a written communication to the Agency’s Executive Director at the time the application is filed.

Consent Calendar NOT Requested

4E. PROJECT COST CHART — N/A

A.	Construction and equipment acquired by purchase:
	1.	Architectural and Engineering Fees	__________________
	2.	Legal, Administrative (Excluding CON Filing Fee), Consultant Fees	__________________
	3.	Acquisition of Site	__________________
	4.	Preparation of Site	__________________
	5.	Total Construction Costs	__________________
	6.	Contingency Fund	__________________
	7.	Fixed Equipment (Not included in Construction Contract)	__________________
	8.	Moveable Equipment (List all equipment over $50,000 as separate attachments)	__________________
	9.	Other (Specify) ___________________________	__________________
B.	Acquisition by gift, donation, or lease:
	1.	Facility (inclusive of building and land)	__________________
	2.	Building only	__________________
	3.	Land only	__________________
	4.	Equipment (Specify)______________________	__________________
	5.	Other (Specify) __________________________	__________________
C.	Financing Costs and Fees:
	1.	Interim Financing	__________________
	2.	Underwriting Costs	__________________
	3.	Reserve for One Year’s Debt Service	__________________
	4.	Other (Specify) ___________________________	__________________
D.	Estimated Project Cost (A+B+C)	__________________
E.		CON Filing Fee	__________________
F.		Total Estimated Project Cost (D+E) TOTAL	__________________

GENERAL CRITERIA FOR CERTIFICATE OF NEED

In accordance with TCA §68-11-1609(b), “no Certificate of Need shall be granted unless the action proposed in the application for such Certificate is necessary to provide needed health care in the area to be served, will provide health care that meets appropriate quality standards, and the effect attributed to completion or duplication would be positive for consumers.” In making determinations, the Agency uses as guidelines the goals, objectives, criteria, and standards adopted to guide the agency in issuing certificates of need. Until the agency adopts its own criteria and standards by rule, those in the state health plan apply. Link to Criteria and Standards: Standards:

Additional criteria for review are prescribed in Chapter 11 of the Agency Rules, Tennessee Rules and Regulations 01730-11.

The following questions are listed according to the three criteria: (1) Need, (2) the effects attributed to competition or duplication would be positive for consumers (Consumer Advantage), and (3) Quality Standards.

NEED

The responses to this section of the application will help determine whether the project will provide needed health care facilities or services in the area to be served.

1N.Provide responses as an attachment to the applicable criteria and standards for the type of institution or service requested. A word version and pdf version for each reviewable type of institution or service are located at the following website. .

RESPONSE: [Students – You do not have to respond to the Criteria and Standards. However, you must attach a copy of the Criteria and Standards which would be applicable to your type of project (hospital, nursing home, etc. from the website – link is above) to show me you went to the website and chose the correct set of criteria. Label the first page of the attachment “Attachment 1N .”]

2N.Identify the proposed service area and provide justification for its reasonableness. Submit a county level map for the Tennessee portion and counties boarding the state of the service area using the supplemental map, clearly marked, and shaded to reflect the service area as it relates to meeting the requirements for CON criteria and standards that may apply to the project. Please include a discussion of the inclusion of counties in the border states, if applicable. (Attachment 2N). N/A

Complete the following utilization tables for each county in the service area, if applicable. N/A

Service Area Counties	Projected Utilization-County Residents to be Served – Year 1 (Year=__________)	% of Total Procedures Cases Patients Other (Specify): __________
County #1
County #2
County #3
Etc.
Total		100%

4N.Describe the special needs of the service area population, including health disparities, the accessibility to consumers, particularly those who are uninsured or underinsured, the elderly, women, racial and ethnic minorities, TennCare or Medicaid recipients, and low income groups. Document how the business plans of the facility will take into consideration the special needs of the service area population.

RESPONSE:

CONSUMER ADVANTAGE ATTRIBUTED TO COMPETITION

The responses to this section of the application helps determine whether the effects attributed to competition or duplication would be positive for consumers within the service area.

1C.List all transfer agreements relevant to the proposed project. N/A

2C.List all commercial private insurance plans contracted or plan to be contracted by the applicant. N/A

3C.Describe the effects of competition and/or duplication of the proposal on the health care system, including the impact upon consumer charges and consumer choice of services.

RESPONSE:

6C.See INSTRUCTIONS to assist in completing the following tables. N/A

	HISTORICAL DATA CHART	□ Project Only □ Total Facility
Give information for the last three (3) years for which complete data are available for the facility or agency.
		Year_____	Year_____	Year_____
A.	Utilization Data Specify Unit of Measure _______________	________	________	________
B.	Revenue from Services to Patients
	1.	Inpatient Services	$________	$________	$________
	2.	Outpatient Services	________	________	________
	3.	Emergency Services	________	________	________
	4.	Other Operating Revenue (Specify)____________________	________	________	________
		Gross Operating Revenue	$________	$________	$________
C.	Deductions from Gross Operating Revenue
	1.	Contractual Adjustments	$________	$________	$________
	2.	Provision for Charity Care	________	________	________
	3.	Provisions for Bad Debt	________	________	________
		Total Deductions	$________	$________	$________
NET OPERATING REVENUE	$________	$________	$________

	PROJECTED DATA CHART	□ Project Only □ Total Facility
Give information for the two (2) years following the completion of this proposal.
		Year______	Year______
A.	Utilization Data Specify Unit of Measure _______________	__________	__________
B.	Revenue from Services to Patients
	1	Inpatient Services	$__________	$__________
	2	Outpatient Services	__________	__________
	3	Emergency Services	__________	__________
	4	Other Operating Revenue (Specify)_____________	__________	__________
		Gross Operating Revenue	$__________	$__________
C.	Deductions from Gross Operating Revenue
	1	Contractual Adjustments	$__________	$__________
	2	Provision for Charity Care	__________	__________
	3	Provisions for Bad Debt	__________	__________
		Total Deductions	$__________	$__________
NET OPERATING REVENUE	$__________	$__________

7C.Please identify the project’s average gross charge, average deduction from operating revenue, and average net charge using information from the Historical and Projected Data Charts of the proposed project. N/A

Project Only Chart N/A

	Previous Year to Most Recent Year Year ____	Most Recent Year Year____	Year One Year___	Year Two Year____	% Change (Current Year to Year 2)
Gross Charge (Gross Operating Revenue/Utilization Data)
Deduction from Revenue (Total Deductions/Utilization Data)
Average Net Charge (Net Operating Revenue/Utilization Data)

8C.Provide the proposed charges for the project and discuss any adjustment to current charges that will result from the implementation of the proposal. Additionally, describe the anticipated revenue from the project and the impact on existing patient charges.

N/A

9C.Compare the proposed project charges to those of similar facilities/services in the service area/adjoining services areas, or to proposed charges of recently approved Certificates of Need. If applicable, compare the proposed charges of the project to the current Medicare allowable fee schedule by common procedure terminology (CPT) code(s).

N/A

Question: Questions 6C-9C examine charges to consumers. Please explain why you think health care providers “charges” are important, in light of the fact insurance companies pay much of those charges.

RESPONSE:

10C.Discuss the project’s participation in state and federal revenue programs, including a description of the extent to which Medicare, TennCare/Medicaid, and medically indigent patients will be served by the project. Report the estimated gross operating revenue dollar amount and percentage of project gross operating revenue anticipated by payor classification for the first year of the project by completing the table below.

N/A

Applicant’s Projected Payor Mix

Project Only Chart N/A

Payor Source	Year 1	Year 2
	Gross Operating Revenue	% of Total	Gross Operating Revenue	% of Total
Medicare/Medicare Managed Care
TennCare/Medicaid
Commercial/Other Managed Care
Self-Pay
Other (Specify)________________
Total*
Charity Care

*Needs to match Gross Operating Revenue Year One and Year Two on Projected Data Chart

Question: Why is the Payor Mix important? What state interests are at stake here?

RESPONSE:

QUALITY STANDARDS

1Q.Per PC 1043, Acts of 2016, any receiving a CON after July 1, 2016, must report annually using forms prescribed by the Agency concerning appropriate quality measures. Please attest that the applicant will submit an annual Quality Measure report when due.

RESPONSE:

2Q.The proposal shall provide health care that meets appropriate quality standards. Please address each of the following questions.

· Does the applicant commit to maintaining the staffing comparable to the staffing chart presented in its CON application?

· Does the applicant commit to obtaining and maintaining all applicable state licenses in good standing?

· Does the applicant commit to obtaining and maintaining TennCare and Medicare certification(s), if participation in such programs are indicated in the application?

RESPONSE:

7Q.Respond to all of the following and for such occurrences, identify, explain, and provide documentation if occurred in last five (5) years. N/A

Has any of the following:

· Any person(s) or entity with more than 5% ownership (direct or indirect) in the applicant (to include any entity in the chain of ownership for applicant);

· Any entity in which any person(s) or entity with more than 5% ownership (direct or indirect) in the applicant (to include any entity in the chain of ownership for applicant) has an ownership interest of more than 5%; and/or

Been subject to any of the following:

· Final Order or Judgement in a state licensure action;

· Criminal fines in cases involving a Federal or State health care offense;

· Civil monetary penalties in cases involving a Federal or State health care offense;

· Administrative monetary penalties in cases involving a Federal or State health care offense;

· Agreement to pay civil or administrative monetary penalties to the federal government or any state in cases involving claims related to the provision of health care items and services;

· Suspension or termination of participation in Medicare or TennCare/Medicaid programs; and/or

· Is presently subject of/to an investigation, or party in any regulatory or criminal action of which you are aware.

Question: Assuming these actions are under the authority of a federal agency and/or a state agency other than HSDA (which is the case), why is this question included in the CON application?

RESPONSE:

DEVELOPMENT SCHEDULE

TCA §68-11-1609(c) provides that activity authorized by a Certificate of Need is valid for a period not to exceed three (3) years (for hospital and nursing home projects) or two (2) years (for all other projects) from the date of its issuance and after such time authorization expires; provided, that the Agency may, in granting the Certificate of Need, allow longer periods of validity for Certificate of Need for good cause shown. Subsequent to granting the Certificate of Need, the Agency may extend a Certificate of Need for a period upon application and good cause shown, accompanied by a non-refundable reasonable filing fee, as prescribed by rule. A certificate of Need authorization which has been extended shall expire at the end of the extended time period. The decision whether to grant an extension is within the sole discretion of the Agency, and is not subject to review, reconsideration, or appeal.

· Complete the Project Completion Forecast Chart below. If the project will be completed in multiple phases, please identify the anticipated completion date for each phase.

· If the CON is granted and the project cannot be completed within the standard completion time period (3 years for hospital and nursing home projects and 2 years for all others), please document why an extended period should be approved and document the “good cause” for such an extension.

PROJECT COMPLETION FORECAST CHART

Assuming the Certificate of Need (CON) approval becomes the final HSDA action on the date listed in Item 1 below, indicate the number of days from the HSDA decision date to each phase of the completion forecast. N/A

Phase	Days Required	Anticipated Date (Month/Year)
1. Initial HSDA Decision Date
2. Building Construction Commenced
3. Construction 100% Complete (Approval for Occupancy)
4. Issuance of License
5. Issuance of Service
6. Final Project Report Form Submitted (Form HR0055)