ࡱ> c $Sbjbj $؎U\؎U\@~Ltt  $&&&Pv ! &lvF,:0(b0b0b02<3T3,CuEuEuEuEuEuEu$y{^iu&52"2&5&5iub0b0.&v:::&5b0b0Cu:&5Cu::Nskopb0/>6m0/u3,:&4$J4333iuiu 9333lv&5&5&5&5|333333333t> :  Craig P. Tanio, M.D. Ben Steffen CHAIR EXECUTIVE DIRECTOR MARYLAND HEALTH CARE COMMISSION 4160 PATTERSON AVENUE BALTIMORE, MARYLAND 21215 TELEPHONE: 410-764-3460 FAX: 410-358-1236 INSTRUCTIONS FOR APPLICATION FOR CERTIFICATE OF NEED HOME HEALTH AGENCY PROJECTS ALL APPLICATIONS MUST FOLLOW THE FORMATTING REQUIREMENTS DESCRIBED IMMEDIATELY BELOW. NOT FOLLOWING THESE FORMATTING INSTRUCTIONS WILL RESULT IN THE APPLICATION BEING RETURNED. REQUIRED FORMAT: Table of Contents. The application must include a Table of Contents referencing the location of application materials. Each section in the hard copy submission should be separated with tabbed dividers. Any exhibits, attachments, etc. should be similarly tabbed, and pages within each should be numbered independently and consecutively. The Table of Contents must include: Responses to PARTS I, II, III and IV of this application form Responses to PART II must include responses to the standards in the State Health Plan chapter, COMAR 10.24.16, STATE HEALTH PLAN FOR FACILITIES AND SERVICES: HOME HEALTH AGENCY SERVICES. Identification of each Attachment, Exhibit, or Supplement Application pages must be consecutively numbered at the bottom of each page. Exhibits attached to subsequent correspondence during the completeness review process shall use a consecutive numbering scheme, continuing the sequencing from the original application. (For example, if the last exhibit in the application is Exhibit 5, any exhibits used in subsequent responses should begin with Exhibit 6. However, a replacement exhibit that merely replaces an exhibit to the application should have the same number as the exhibit it is replacing, noted as a replacement.) SUBMISSION FORMATS: We require submission of application materials in three forms: hard copy; searchable PDF; and in Microsoft Word. Hard copy: Applicants must submit six (6) hard copies of the application to: Ruby Potter Health Facilities Coordinator Maryland Health Care Commission 4160 Patterson Avenue Baltimore, Maryland 21215 PDF: Applicants must also submit searchable PDF files of the application, supplements, attachments, and exhibits.. All subsequent correspondence should also be submitted both by paper copy and as searchable PDFs. Microsoft Word: Responses to the questions in the application and the applicants responses to completeness questions should also be electronically submitted in Word. Applicants are strongly encouraged to submit any spreadsheets or other files used to create the original tables (the native format). This will expedite the review process. PDFs and spreadsheets should be submitted to  HYPERLINK "mailto:ruby.potter@maryland.gov" ruby.potter@maryland.gov and  HYPERLINK "mailto:kevin.mcdonald@maryland.gov" kevin.mcdonald@maryland.gov. Note that there are certain actions that may be taken regarding either a health care facility or an entity that does not meet the definition of a health care facility where CON review and approval are not required. Most such instances are found in the Commissions procedural regulations at COMAR 10.24.01.03, .04, and .05. Instances listed in those regulations require the submission of specified information to the Commission and may require approval by the full Commission. Contact CON staff at (410) 764-3276 for more information. PART I - PROJECT IDENTIFICATION AND GENERAL INFORMATION 1. APPLICANT. If the application has a co-applicant, provide the following information for that party in an attachment. Legal Name of Project Applicant (Licensee or Proposed Licensee): FORMTEXT       Address: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      StreetCityZipStateCounty Telephone: FORMTEXT       Name of Owner/Chief Executive:  FORMTEXT       2. Name of Owner_______________________________________  FORMTEXT       If Owner is a Corporation, Partnership, or Limited Liability Company, attach a description of the ownership structure identifying all individuals that have or will have at least a 5% ownership share in the applicant and any related parent entities. Attach a chart that completely delineates this ownership structure.  3. FACILITY Name of HHA provider:  FORMTEXT       Address: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      StreetCityZipCounty Name of Owner (if differs from applicant): FORMTEXT       4. Name of Licensee or Proposed Licensee, if different from the applicant:  FORMTEXT      5. LEGAL STRUCTURE OF APPLICANT (and licensee, if different from applicant). Check ( or fill in applicable information below and attach an organizational chart showing the owners of applicant (and licensee, if different). A. Governmental  FORMCHECKBOX  B. Corporation (1) Non-profit  FORMCHECKBOX  (2) For-profit  FORMCHECKBOX  (3) Close  FORMCHECKBOX  State & Date of Incorporation  FORMTEXT       C. Partnership General  FORMCHECKBOX  Limited  FORMCHECKBOX  Limited Liability Partnership  FORMCHECKBOX  Limited Liability Limited Partnership  FORMCHECKBOX  Other (Specify):  FORMTEXT       D. Limited Liability Company  FORMCHECKBOX  E. Other (Specify):  FORMTEXT       To be formed:  FORMCHECKBOX  Existing:  FORMCHECKBOX  6. PERSON(S) TO WHOM QUESTIONS REGARDING THIS APPLICATION SHOULD BE DIRECTED  A. Lead or primary contact: Name and Title: Mailing Address:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street City Zip State Telephone:  FORMTEXT       E-mail Address (required):  FORMTEXT       Fax:  FORMTEXT       B. Additional or alternate contact: Mailing Address:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street City Zip State Telephone:  FORMTEXT       E-mail Address (required):  FORMTEXT       Fax:  FORMTEXT        B. Additional or alternate contact: Name and Title:  FORMTEXT       Company Name  FORMTEXT      Mailing Address: FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT      StreetCityZipState Telephone:  FORMTEXT      E-mail Address (required):  FORMTEXT      Fax:  FORMTEXT       If company name is different than applicant briefly describe the relationship  FORMTEXT        7. Proposed Agency Type: ( a. Health Department ___ b. Hospital-Based ___ c. Nursing Home-Based ___ d. Continuing Care Retirement Community-Based ___ e. HMO-Based ___ f. Freestanding ___ g. Other ___ (Please Specify.) ____________________________________________ 8. Agency Services (Please check ( all applicable.) Service Currently Provided  Proposed to be Provided in the Jurisdiction(s) that are the subject of this Application*Skilled Nursing ServicesHome Health AideOccupational TherapySpeech, Language TherapyPhysical TherapyMedical Social Services* If proposing different services in different jurisdictions, note that accordingly. 9. Offices Identify the address of all existing main office, subunit office, and branch office locations and identify the location (city and county) of all proposed main office, subunit office, and branch offices, as applicable. (Add rows as needed.) StreetCityCountyStateZip CodeTelephoneExisting Main OfficeExisting Subunit OfficesExisting Branch OfficesLocations of Proposed HHA Main OfficeLocations of Proposed HHA Subunit OfficeLocations of Proposed Branch Office 10. Project Implementation Target Dates A. Licensure: ______months from CON approval date. B. Medicare Certification _______months from CON approval date. NOTE: in completing this question, please note that Commission regulations at COMAR 10.24.01.12 state that home health agencies have up to 18 months from the date of the certificate of need to: (i) become licensed and Medicare certified; and (ii) begin operations in the jurisdiction for which the certificate of need was granted. 11. Project Description: Provide a summary description of the project immediately below. At minimum, include the jurisdictions to be served and all of the types of home health agency services to be established, expanded, or otherwise affected if the project receives approval. PART II - CONSISTENCY WITH REVIEW CRITERIA AT COMAR 10.24.01.08G(3): INSTRUCTION: Each applicant must respond to all applicable criteria included in COMAR 10.24.01.08G. These criteria follow, 10.24.01.08G(3)(a) through 10.24.01.08G(3)(f). 10.24.01.08G(3)(a). The State Health Plan Review Criterion An application for a Certificate of Need shall be evaluated according to all relevant State Health Plan standards, policies, and criteria. (Note: In this case it is the standards at COMAR 10.24.16.08 and in the case of comparative reviews, at COMAR 10.24.16.09.) 10.24.16.08 Certificate of Need Review Standards for Home Health Agency Services. The Commission shall use the following standards, as applicable, to review an application for a Certificate of Need to establish a new home health agency in Maryland or expand the services of an existing Maryland home health agency to one or more additional jurisdictions. The following standards must be addressed by all home health agency CON applicants, as applicable. Provide a direct, concise response explaining the proposed project's consistency with each standard. In cases where standards require specific documentation, please include the documentation as a part of the application. 10.24.16.08A. Service Area. An applicant shall: (1) Designate the jurisdiction or jurisdictions in which it proposes to provide home health agency services; and (2) Provide an overall description of the configuration of the parent home health agency and its interrelationships, including the designation and location of its main office, each subunit, and each branch, as defined in this Chapter, or other major administrative offices recognized by Medicare. 10.24.16.08B. Populations and Services. An applicant shall describe the population to be served and the specific services it will provide. 10.24.16.08C. Financial Accessibility. An applicant shall be or agree to become licensed and Medicare- and Medicaid-certified, and agree to maintain Medicare and Medicaid certification and to accept clients whose expected primary source of payment is either or both of these programs. 10.24.16.08D. Fees and Time Payment Plan. An applicant shall make its fees known to prospective clients and their families at time of patient assessment before services are provided and shall: (1) Describe its special time payment plans for an individual who is unable to make full payment at the time services are rendered; and (2) Submit to the Commission and to each client a written copy of its policy detailing time payment options and mechanisms for clients to arrange for time payment. 10.24.16.08 E. Charity Care and Sliding Fee Scale. Each applicant for home health agency services shall have a written policy for the provision of charity care for indigent and uninsured patients to ensure access to home health agency services regardless of an individuals ability to pay and shall provide home health agency services on a charitable basis to qualified indigent and low income persons consistent with this policy. The policy shall include provisions for, at a minimum, the following: (1) Determination of Eligibility for Charity Care and Reduced Fees. Within two business days following a clients initial request for charity care services, application for medical assistance, or both, the home health agency shall make a determination of probable eligibility for medical assistance, charity care, and reduced fees, and communicate this probable eligibility determination to the client. (2) Notice of Charity Care and Sliding Fee Scale Policies. Public notice and information regarding the home health agencys charity care and sliding fee scale policies shall be disseminated, on an annual basis, through methods designed to best reach the population in the HHAs service area, and in a format understandable by the service area population. Notices regarding the HHAs charity care and sliding fee scale policies shall be posted in the business office of the HHA and on the HHAs website, if such a site is maintained. Prior to the provision of HHA services, a HHA shall address clients or clients families concerns with payment for HHA services, and provide individual notice regarding the HHAs charity care and sliding fee scale policies to the client and family. (3) Discounted Care Based on a Sliding Fee Scale and Time Payment Plan Policy. Each HHAs charity care policy shall include provisions for a sliding fee scale and time payment plans for low-income clients who do not qualify for full charity care, but are unable to bear the full cost of services. (4) Policy Provisions. An applicant proposing to establish a home health agency or expand home health agency services to a previously unauthorized jurisdiction shall make a commitment to, at a minimum, provide an amount of charity care equivalent to the average amount of charity care provided by home health agencies in the jurisdiction or multi-jurisdictional region it proposes to serve during the most recent year for which data is available. The applicant shall demonstrate that: (a) Its track record in the provision of charity care services, if any, supports the credibility of its commitment; and (b) It has a specific plan for achieving the level of charity care to which it is committed. 10.24.16.08 F. Financial Feasibility. An applicant shall submit financial projections for its proposed project that must be accompanied by a statement containing the assumptions used to develop projections for its operating revenues and costs. Each applicant must document that: (1) Utilization projections are consistent with observed historic trends of HHAs in each jurisdiction for which the applicant seeks authority to provide home health agency services; (2) Projected revenue estimates are consistent with current or anticipated charge levels, rates of reimbursement, contractual adjustments and discounts, bad debt, and charity care provision, as experienced by the applicant if an existing HHA or, if a proposed new HHA, consistent with the recent experience of other Maryland HHAs serving each proposed jurisdiction; and (3) Staffing and overall expense projections are consistent with utilization projections and are based on current expenditure levels and reasonably anticipated future staffing levels as experienced by the applicant if an existing HHA or, if a proposed new HHA, consistent with the recent experience of other Maryland HHAs serving the each proposed jurisdiction. 10.24.16.08G. Impact. An applicant shall address the impact of its proposed home health agency service on each existing home health agency authorized to serve each jurisdiction or regional service area affected by the proposed project. This shall include impact on existing HHAs caseloads, staffing and payor mix. 10.24.16.08H. Financial Solvency. An applicant shall document the availability of financial resources necessary to sustain the project. Documentation shall demonstrate an applicants ability to comply with the capital reserve and other solvency requirements specified by CMS for a Medicare-certified home health agency. 10.24.16.08I. Linkages with Other Service Providers. An applicant shall document its links with hospitals, nursing homes, continuing care retirement communities, hospice programs, assisted living providers, Adult Evaluation and Review Services, adult day care programs, the local Department of Social Services, and home delivered meal programs located within its proposed service area. (1) A new home health agency shall provide this documentation when it requests first use approval. (2) A Maryland home health agency already licensed and operating shall provide documentation of these linkages in its existing service area and document its work in forming such linkages before beginning operation in each new jurisdiction it is authorized to serve. 10.24.16.08J. Discharge Planning. An applicant shall document that it has a formal discharge planning process including the ability to provide appropriate referrals to maintain continuity of care. It will identify all the valid reasons upon which it may discharge clients or transfer clients to another health care facility or program. 10.24.16.08K. Data Collection and Submission. An applicant shall demonstrate ongoing compliance or ability to comply with all applicable federal and State data collection and reporting requirements including, but not limited to, the Commissions Home Health Agency Annual Survey, CMS Outcome and Assessment Information Set (OASIS), and CMS Home Health Consumer Assessment of Healthcare Providers (HHCAHPS). 10.24.16.09 Certificate of Need Preference Rules in Comparative Reviews. Consistent with COMAR 10.24.01.09A(4)(b), the Commission shall use the following preferences, in the order listed, to limit the number of CON applications approved in a comparative review. 10.24.16.09A. Performance on Quality Measures. Higher levels of performance will be given preference over lower levels of performance. 10.24.16.09B. Maintained or Improved Performance. An applicant that demonstrates maintenance or improvement in its level of performance on the selected process and outcome measures during the most recent three-year reporting period will be given preference over an applicant that did not maintain or improve its performance. 10.24.16.09C. Proven Track Record in Serving all Payor Types, the Indigent and Low Income Persons. An applicant that served a broader range of payor types and the indigent will be given preference over an applicant that served a narrower range of payor types and provided less service to the indigent and low income persons. 10.24.16.09D. Proven Track Record in Providing a Comprehensive Array of Services. An applicant that provided a broader range of services will be given preference over an applicant that provided a narrower range of services. 10.24.16.09E. These preferences will only be used in a comparative review of applications when it is determined that approval of all applications that fully comply with standards in Regulation .08 of this Chapter would exceed the permitted number of additional HHAs provided for in a jurisdiction or multi-jurisdictional region as provided in Regulation .10. 10.24.01.08G(3)(b). The Need Review Criterion The Commission shall consider the applicable need analysis in the State Health Plan. If no State Health Plan need analysis is applicable, the Commission shall consider whether the applicant has demonstrated unmet needs of the population to be served, and established that the proposed project meets those needs. Please discuss the need of the population served or to be served by the Project. Recognizing that the State Health Plan has identified need to establish an opportunity for review of CON applications in certain jurisdictions based on the determination that the identified jurisdiction(s) has insufficient consumer choice of HHAs, a highly concentrated HHA service market, or an insufficient choice of HHAs with high quality performance (COMAR 10.24.16.04), applicants are expected to provide a quantitative analysis that, at a minimum, describes the Project's expected service area; population size, characteristics, and projected growth; and, projected home health services utilization. 10.24.01.08G(3)(c). The Availability of More Cost-Effective Alternatives Review Criterion The Commission shall compare the cost-effectiveness of the proposed project with the cost-effectiveness of providing the service through alternative existing facilities, or through an alternative facility that has submitted a competitive application as part of a comparative review.  Please explain the characteristics of the Project which demonstrate why it is a less costly and/or a more effective alternative for meeting the needs identified than other types of projects or approaches that could be developed for meeting those same needs or most of the needs. A clear statement of project objectives should be outlined. Alternative approaches to meeting these objectives should be fully described. The effectiveness of each alternative in meeting the project objectives should be evaluated and the cost of each alternative should be estimated. For applications proposing to demonstrate superior patient care effectiveness, please describe the characteristics of the Project that will assure the quality of care to be provided. These may include, but are not limited to: meeting quality measures and performance benchmarks established by the Commission; meeting accreditation standards, personnel qualifications of caregivers, special relationships with public agencies for patient care services affected by the Project, the development of community-based services or other characteristics the Commission should take into account. 10.24.01.08G(3)(d). The Viability of the Proposal Review Criterion. The Commission shall consider the availability of financial and nonfinancial resources, including community support, necessary to implement the project within the time frames set forth in the Commission's performance requirements, as well as the availability of resources necessary to sustain the project.  Please include in your response: a. Audited Financial Statements for the past two years. In the absence of audited financial statements, provide documentation of the adequacy of financial resources to fund this project signed by a Certified Public Accountant who is not directly employed by the applicant. The availability of each source of funds listed in Part IV, Table 1 B. Sources of Funds for Project, must be documented. b. Existing home health agencies shall provide an analysis of the probable impact of the project on its costs and charges for the services it provides. Non-home health agency applicants should address the probable impact of the project on the costs and charges for core services they provide. c. A discussion of the probable impact of the project on the cost and charges for similar services provided by other home health agencies in the area. d. All applicants shall provide a detailed list of proposed patient charges for affected services. e. A discussion of the staffing and workforce implications of this proposed project, including: An assessment of the sources available for recruiting additional personnel; A description of your plans for recruitment and retention of personnel believed to be in short supply; A report on the average vacancy rate and turnover rates for affected positions in the last year. Completion of Table 5 in the Charts and Tables Supplement (Part IV). 10.24.01.08G(3)(e). The Compliance with Conditions of Previous Certificates of Need Review Criterion. An applicant shall demonstrate compliance with all terms and conditions of each previous Certificate of Need granted to the applicant, and with all commitments made that earned preferences in obtaining each previous Certificate of Need, or provide the Commission with a written notice and explanation as to why the conditions or commitments were not met.  List all prior Certificates of Need that have been issued since 1990 to the project applicant or to any entity which included, as principals, persons with ownership or control interest in the project applicant. Identify the terms and conditions, if any, associated with these CON approvals and any commitments made that earned preferences in obtaining any of the CON approvals. Report on the status of the approved projects, compliance with terms and conditions of the CON approvals and commitments made. 10.24.01.08G(3)(f). The Impact on Existing Providers Review Criterion. An applicant shall provide information and analysis with respect to the impact of the proposed project on existing health care providers in the health planning region, including the impact on geographic and demographic access to services, on occupancy, on costs and charges of other providers, and on costs to the health care delivery system.  INSTRUCTIONS: Please provide an analysis of the impact of the proposed project. Please assure that all sources of information used in the impact analysis are identified and identify all the assumptions made in the impact analysis with respect to demand for services, payer mix, access to service and cost to the health care delivery system including relevant populations considered in the analysis, and changes in market share, with information that supports the validity of these assumptions. Provide an analysis of the following impacts: a) On the volume of service provided by all other existing health care providers that are likely to experience some impact as a result of this project; b) On the payer mix of all other existing health care providers that are likely to experience some impact on payer mix as a result of this project. If an applicant for a new nursing home claims no impact on payer mix, the applicant must identify the likely source of any expected increase in patients by payer. c) On access to health care services for the service area population that will be served by the project. (State and support the assumptions used in this analysis of the impact on access); d) On costs to the health care delivery system. If the applicant is an existing provider, submit a summary description of the impact of the proposed project on the applicants costs and charges, consistent with the information provided in the Project Budget, the projections of revenues and expenses, and the work force information. PART III - APPLICANT HISTORY, STATEMENT OF RESPONSIBILITY, AUTHORIZATION AND SIGNATURE 1. List the name and address of each owner or other person responsible for the proposed project and its implementation. If the applicant is not a natural person, provide the date the entity was formed, the business address of the entity, the identify and percentage of ownership of all persons having an ownership interest in the entity, and the identification of all entities owned or controlled by each such person. ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 2. Is the applicant, or any person listed above now involved, or ever been involved, in the ownership, development, or management of another health care facility or program? If yes, provide a listing of each facility or program, including facility name, address, and dates of involvement. _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ 3. Has the Maryland license or certification of the applicant home health agency, or any of the facilities or programs listed in response to Questions 1 and 2, above, ever been suspended or revoked, or been subject to any disciplinary action (such as a ban on admissions) in the last 5 years? If yes, provide a written explanation of the circumstances, including the date(s) of the actions and the disposition. If the applicant, owner or other person responsible for implementation of the Project was not involved with the facility or program at the time a suspension, revocation, or disciplinary action took place, indicate in the explanation. _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Is any facility or program with which the applicant is involved, or has any facility or program with which the applicant or other person or entity listed in Questions 1 & 2, above, ever been found out of compliance with Maryland or Federal legal requirements for the provision of, payment for, or quality of health care services (other than the licensure or certification actions described in the response to Question 3, above) which have led to an action to suspend, revoke or limit the licensure or certification at any facility or program. If yes, provide copies of the findings of non-compliance including, if applicable, reports of non-compliance, responses of the facility or program, and any final disposition reached by the applicable governmental authority. _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ 5. Has the applicant, or other person listed in response to Question 1, above, ever pled guilty to or been convicted of a criminal offense connected in any way with the ownership, development or management of the applicant facility or program or any health care facility or program listed in response to Question 1 & 2, above? If yes, provide a written explanation of the circumstances, including the date(s) of conviction(s) or guilty plea(s). ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ One or more persons shall be officially authorized in writing by the applicant to sign for and act for the applicant for the project which is the subject of this application. Copies of this authorization shall be attached to the application. The undersigned is the owner(s), or authorized agent of the applicant for the proposed home healthy agency service. I hereby declare and affirm under the penalties of perjury that the facts stated in this application and its attachments are true and correct to the best of my knowledge, information and belief. ____________________ __________________________ Date Signature of Owner or Authorized Agent of the Applicant Part IV: Home Health Agency Application: Charts and Tables Supplement TABLE 1 - PROJECT BUDGET TABLE 2A: STATISTICAL PROJECTIONS FOR HHA SERVICES IN MARYLAND TABLE 2B: STATISTICAL PROJECTIONS FOR PROPOSED JURSIDICTIONS TABLE 3: REVENUES AND EXPENSES - FOR HHA SERVICES IN MARYLAND TABLE 4: REVENUES AND EXPENSES - PROPOSED PROJECT TABLE 5: STAFFING INFORMATION TABLE 1: Project Budget Instructions: All estimates for 1a- d; 2a- f; and 3 are for current costs as of the date of application submission and should include the costs for all intended construction and renovations to be undertaken. Inflation from date of submission of project completion should only be included on the Inflation line 1e. (DO NOT CHANGE THIS FORM OR ITS LINE ITEMS. IF ADDITIONAL DETAIL OR CLARIFICATION IS NEEDED, ATTACH ADDITIONAL SHEET.) A. USE OF FUNDS1. CAPITAL COSTS (if applicable):New Construction Building$Fixed Equipment (not included in construction)Architect/Engineering FeesPermits, (Building, Utilities, Etc)a. SUBTOTAL New Construction $RenovationsBuilding$Fixed Equipment (not included in construction)Architect/Engineering FeesPermits, (Building, Utilities, Etc.)b. SUBTOTAL Renovations $Other Capital CostsMovable EquipmentContingency Allowance Gross Interest During ConstructionOther (Specify)c. SUBTOTAL Other Capital Cost $TOTAL CURRENT CAPITAL COSTS (sum of a - c)$Non-Current Capital CostLand Purchase Cost or Value of Donated Land$Inflation (state all assumptions, including time period and rate$TOTAL PROPOSED CAPITAL COSTS (sum of a - e)$2. FINANCING COST AND OTHER CASH REQUIREMENTSLoan Placement Fees$Bond Discount CON Application Assistancec1. Legal Fees c2 Other (Specify and add lines as needed)d. Non-CON Consulting Feesd1. Legal Fees d2. Other (Specify and add lines as needed)e. Debt Service Reserve Fundf. Other (Specify)TOTAL (a - e) $3. WORKING CAPITAL STARTUP COSTS$TOTAL USES OF FUNDS (sum of 1 - 3)$ B. SOURCES OF FUNDS FOR PROJECTCash Pledges: Gross __________,less allowance for uncollectables __________= NetGifts, bequestsAuthorized BondsInterest income (gross)MortgageWorking capital loans Grants or AppropriationFederalStateLocalOther (Specify)TOTAL SOURCES OF FUNDS (sum of 1-9)$ANNUAL LEASE COSTS (if applicable)LandBuildingMoveable equipmentOther (specify) TABLE 2A: STATISTICAL PROJECTIONS HISTORIC AND PROJECTED HOME HEALTH AGENCY SERVICES IN MARYLAND Instructions: Table 2A applies to an applicant that is an existing home health agency, and should be completed showing historic and projected utilization for all home health agency services provided in Maryland. Table should report an unduplicated count of clients, and should indicate whether the reporting period is Calendar Year (CY) or Fiscal Year (FY). Two Most Current Actual YearsProjected years ending with first year at full utilizationCY or FY (circle)20__20__20__20__ Client VisitsBillableNon-BillableTOTAL# of Clients and Visits by DisciplineTotal Clients (Unduplicated Count) Skilled Nursing Visits Home Health Aide VisitsPhysical Therapy VisitsOccupational Therapy VisitsSpeech Therapy VisitsMedical Social Services VisitsOther Visits (Please Specify) TABLE 2B: STATISTICAL PROJECTIONS - PROJECTED HOME HEALTH AGENCY SERVICES IN THE PROPOSED PROJECT Instructions: All applicants should complete Table 2B for the proposed project, showing projected utilization only for the jurisdiction(s) which is the subject of the application. As in Table 2A above, this table should report an unduplicated count of clients, and should indicate whether the reporting period is Calendar Year (CY) or Fiscal Year (FY). Projected years ending with first year at full utilizationCY or FY (circle)20__20__20__20__Client VisitsBillableNon-BillableTOTAL# of Clients and Visits by DisciplineTotal Clients (Unduplicated Count) Skilled Nursing Visits Home Health Aide VisitsPhysical Therapy VisitsOccupational Therapy VisitsSpeech Therapy VisitsMedical Social Services VisitsOther Visits (Please Specify) TABLE 3: REVENUES AND EXPENSES HISTORIC AND PROJECTED HOME HEALTH AGENCY SERVICES IN MARYLAND (including proposed project) Instructions: an existing home health agency must complete Table 3, showing historic and projected revenues and expenses for all home health agency services provided in Maryland. Projections should be presented in current dollars. Medicaid revenues for all years should be calculated on the basis of Medicaid rates and ceilings in effect at the time of submission of this application. Specify sources of non-operating income. State the assumptions used in projecting all revenues and expenses. Please indicate on the Table if the reporting period is Calendar Year (CY) or Fiscal Year (FY). Two Most Recent Years -- ActualCurrent Year ProjectedProjected Years (ending with first full year at full utilization)CY or FY (Circle)20___20___20___20___20___20___20___1. RevenueGross Patient Service RevenueAllowance for Bad DebtContractual AllowanceCharity CareNet Patient Services RevenueOther Operating Revenues (Specify)Net Operating Revenue2. ExpensesSalaries, Wages, and Professional Fees, (including fringe benefits)Contractual Services (please specify)Interest on Current DebtInterest on Project DebtCurrent DepreciationProject DepreciationCurrent AmortizationProject AmortizationSuppliesOther Expenses (Specify)Total Operating Expenses3. IncomeIncome from OperationNon-Operating IncomeSubtotalIncome TaxesNet Income (Loss)Table 3 Cont.Two Most Actual Ended Recent YearsCurrent Year ProjectedProjected Years (ending with first full year at full utilization)CY or FY (Circle)20___20___20___20___20___20___20___4A. - Payor Mix as Percent of Total Revenue  Medicare MedicaidBlue CrossCommercial Insurance Self-PayOther (Specify)TOTAL REVENUE 100%100%100%100%100%100%100%4B. Payor Mix as Percent of Total Visits  Medicare Medicaid Blue CrossOther Commercial Insurance Self-PayOther (Specify) TOTAL VISITS100%100%100%100%100%100%100% NOTE: ALL EXISTING FACILITY APPLICANTS MUST SUBMIT AUDITED FINANCIAL STATEMENTS. TABLE 4: REVENUES AND EXPENSES PROJECTED HOME HEALTH AGENCY SERVICES FOR PROPOSED PROJECT Instructions: Complete Table 4 for the proposed project, showing projected revenues and expenses for only the jurisdiction(s) which is the subject of the application. Projections should be presented in current dollars. Medicaid revenues for all years should be calculated on the basis of Medicaid rates and ceilings in effect at the time of submission of this application. 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State the assumptions used in projecting all revenues and expenses. Please indicate on the Table if the reporting period is Calendar Year (CY) or Fiscal Year (FY). Projected Years (ending with first full year at full utilization)CY or FY (Circle)20___20___20___20___1. RevenueGross Patient Service RevenueAllowance for Bad DebtContractual Allowance Charity CareNet Patient Services RevenueOther Operating Revenues (Specify)Net Operating Revenue2. ExpensesSalaries, Wages, and Professional Fees, (including fringe benefits)Contractual ServicesInterest on Current DebtInterest on Project DebtCurrent DepreciationProject DepreciationCurrent AmortizationProject AmortizationSuppliesOther Expenses (Specify)Total Operating Expenses3. IncomeIncome from OperationNon-Operating IncomeSubtotalIncome TaxesNet Income (Loss) Table 4 Cont.Projected Years (ending with first full year at full utilization)CY or FY (Circle)20___20___20___20___4A. - Payor Mix as Percent of Total RevenueMedicareMedicaidBlue Cross Other Commercial Insurance Other (Specify) TOTAL100%100%100%100%4B. Payor Mix as Percent of Total Visits Medicare Medicaid Blue Cross Other Commercial Insurance Self-Pay Other (Specify) TOTAL100%100%100%100% TABLE 5. STAFFING INFORMATION Instructions: List by service the staffing changes (specifying additions and/or deletions and distinguishing between employee and contractual services) required by this project. FTE data shall be calculated as 2,080 paid hours per year. Indicate the factor to be used in converting paid hours to worked hours. 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