PREVENTIVE AND PRIMARY CARE
PILOT PROGRAM
APPLICATION
Attachment A Attachment B
Applicants must submit completed applications to the HCA on or before November 30,
2007.
PART I
NAME OF INSTITUTION
MAILING ADDRESS
- Address:
– City:
– State:
– Zip:
CONTACT PERSON:
– Name
– Address
– City
– State
– Zip
– Voice Phone
– Fax number
– Email address
MEDICAL DIRECTOR/SUPERVISING PHYSICIAN
FEIN #
PART II
Sponsor Information:
Please provide a brief history/description of the sponsor organization including:
• Governance: When incorporated, who owns/operates, etc.
• Type of Practice: clinic, FQHC, etc. --- public or private
PART III
Clinical Practice Site Information: Provide information for each proposed site.
Service area and population served.
Size: Number of patients (unduplicated count) provided services in the past 12 months.
Provide the number of individuals (unduplicated count) who were uninsured for at least one medical encounter in your facility/facilities in the latest 12 month period.
Staff: List the personnel who will provide services in this program.
Patient Registry: Provide information concerning current electronic record capability, ability to produce information electronically and/or electronic patient referencing capability. Also provide information regarding future plans for further development, if any.
Access: Provide hours and days of operation and after hours coverage information.
Programs: Provide information regarding current care/disease management programs.
Other: Provide other information deemed relevant to this program.
PART IV
Prepaid Program Description:
Please provide a general description of your proposed program. Outline the purpose and intended outcomes of your approach. Please describe the benefit this program will provide to your organization and the communities and patients it serves. If the approach will vary among sites, please provide an explanation why and describe the differences for each site.
Please specifically describe your program, including the following:
1.The method for providing the required, and any additional, services.
2.The application process for enrollees.
3. The groups you intend to enroll – individual, family, employer sponsored groups.
4. The target population for enrollment.
5. The plan to market your program to potential enrollees.
6. Enrollment policies for acceptance, termination, etc.
7. Hours of operation and the provision for after hours coverage.
8. Proposed program fees and payment policies, e.g. frequency of payment, copays, sliding fee scale,
failure to pay policy, discounts. See Attachment B.
9. The method of coordinating referrals to services outside your program and payment for these services.
10. Contract or agreements for the provision of services listed in Attachment A but
not provided on site.
11. The case, care and/or disease management included in your program.
12. The utilization of electronic health information technology.
PART V
Additional Requirements:
Applicants must also provide the following information with their applications:
• Audited financial statements for the last two years. If audited financial statements are not prepared, the applicant must submit personal income tax returns for the last two years. West Virginia Code § 16-2J-8(a) provides that all personal income tax returns files pursuant to this application shall be treated as confidential.
• Fee schedule with supporting data. See Attachment B.
• Proof of medical liability insurance for the applicant and all of the clinicians participating in the program.
• Verification by CEO/Chairman of the board that information contained in application is true and accurate.
A hard copy of the information listed above may be mailed to the West Virginia Health Care Authority, Preventive and Primary Care Pilot Program, c/o Kay Myers, 100 Dee Drive, Charleston, WV 25311.
Attachment B
PREVENTIVE AND PRIMARY CARE PILOT PROGRAM
Fees and Forms
1. Provide a form outlining the services that will be covered with your prepaid program
and indicate any co-pays that may apply. Include any applications that you may
require the participants to submit to be eligible for the services provided.
2. Describe how the fees you plan to charge were determined indicating all
calculations, formulae and variables used and a general description and the source
of each assumption used.
3. In the following, for Services Included in the Base Periodic Fee, provide data as
indicated for all services that you group in your base periodic fee. Under Additional
Services, if you provide other services for an additional periodic fee, please group
all services that each additional periodic fee applies to together and provide the data
indicated. Under Total Number of Patients include the total number of patients
with a minimum of one visit during the period indicated.
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