Certificate of Public Need in Other States Susan Puglisi, Esq. Senior Policy Analyst Virginia Department of Health Office of Licensure and Certification July 1, 2015

Overview and History Certificate of Public Need is more commonly called Certificate of Need (CON) in other states. Many CON laws were initially put into effect as part of the federal Health Planning Resources Development Act of 1974. 35 states including Virginia and the District of Colombia have some form of CON in place.

Overview

State by State: What is regulated? Note: CON is alive and well in SC despite the note on this chart

State by State: What is Regulated? Regulated Services Number of States Nursing Home Beds/Long Term Care Beds 35+DC (including VA) Acute Hospital Beds 28 (including VA) Ambulatory Surgical Centers 27 (including VA) Long Term Acute Care 26 + DC (including VA) Cardiac Catheterization 26 (including VA) Psychiatric Services Rehabilitation 25 (including VA) Open Heart Surgery Radiation Therapy 23 (including VA) Neo-Natal Intensive Care 23 (including VA)

State by State: What is Regulated? Regulated Services Number of States Intermediate Care Facilities for Individuals with Intellectual Disability(ICF/IID) 22 (including VA) Organ Transplants 21 (including VA) Positron Emission Tomography 20 (including VA) Substance/ Drug Abuse 19 Magnetic Resonance Imagining 18 + DC (including VA) Home Health 18 Hospice Mobile Hi Technology (CT/MRI/PET, etc) 15 + DC (Including VA) Obstetrics Services 15 (including VA) Gamma Knives “Additional services regulated” listed in BOLD are subject to COPN in Va Additional services regulated: Air Ambulance, Ambulance services, Burn Care, CT scanners, Lithotripsy, Medical Office Buildings, Renal Failure/Dialysis, Assisted Living Facilities, Subacute Services, Swing Beds, & Ultrasound

State by State: The Review Process VA – 190 days, the longest review period Alabama 50 days Alaska 60 days Arkansas Review is done on a published schedule; 90 days Connecticut 90 days Delaware 90 days D.C. 60 days Florida 60 days Georgia 120 days Hawaii 90 days Illinois 120 days Iowa 60 days Kentucky 90 days Louisiana 60 days Maine 90 days Maryland 150 days Massachusetts 4 months (120 days) Michigan 120 days Mississippi 90 days Missouri 130 days Montana 90 days Nebraska 60 days Nevada 75 days New Hampshire 90 days New Jersey 180 days North Carolina 90 days Ohio 60 days Oklahoma 45 days Oregon 90 days Rhode Island 120 days South Carolina 120 days Tennessee 60 days Vermont 120 days Virginia 190 days Washington 90 days West Virginia 90 days

State by State: Who holds the Authority Alabama Certificate of Need Review Board Alaska Commissioner Arkansas Health Services Permit Commission Connecticut Office of Health Care Access Delaware Bureau of Health Planning and Resources Management D.C. State Health Planning and Development Agency Florida Agency for Health Care Administration Georgia Department of Community Health Hawaii Administrator of the State Health Planning & Development Agency Illinois Health Facilities and Services Review Board Iowa Department of Public Health Kentucky Cabinet for Health and Family Services Louisiana Bureau of Health Services Financing, Health Standards Section, Facility Need Review Program Maine Commissioner of the Department of Health and Human Services Maryland Maryland Health Care Commission Massachusetts Department of Public Health Michigan Director of the Michigan Department of Community Health Mississippi State Health Officer Missouri Missouri Health Facilities Review Committee Montana Department of Public Health and Human Services Nebraska Department of Health and Human Services Nevada Director of the Department of Health and Human Services New Hampshire Health Services Planning and Review Board New Jersey State Commissioner of Health and Senior Services New York Commissioner of Health North Carolina Certificate of Need Section in the Department of Health and Human Services Ohio Director of Health Oklahoma State Commissioner of Health Oregon Public Health Division Rhode Island Rhode Island Department of Health South Carolina Department of Health and Environmental Control Tennessee Tennessee Health Services and Development Agency Vermont Green Mountain Care Board Virginia State Health Commissioner Washington Secretary of the Washington State Department of Health West Virginia West Virginia Health Care Authority

State by State: Application Fees State(s) Maximum Fee South Carolina $7,000 Delaware $10,000 New Hampshire & Alabama $12,000 Michigan $15,000 Ohio, Vermont, Virginia $20,000 Iowa $21,000 Kentucky $25,000 Tennessee $45,000 Washington $46,253 Florida, Georgia, & North Carolina $50,000 Mississippi & Alaska $75,000 Oregon $90,000 Illinois & West Virginia $100,000 Maine $250,000 D.C. $300,000 Alabama 1% of estimated cost, max of $12,000 Alaska $2,500 for projects under $2.5 million 0.1% of projects more than $2.5 million; max of $75,000 Arkansas $3,000 Connecticut $500 Delaware Based on Capital Expenditure, Max $10,000 D.C. 3% of the capital expenditure; min $5,000; max $300,000 Florida 0.15% of capital expenditure; min $10,000; max $50,000 Georgia 0.1% of the total cost; min $1,000; max $50,000 Hawaii $200 + 0.1% of the capital expenditure; and additional 0.05% for expenditures in excess of $1 million Illinois 0.22% of the project cost; min $2,500; max $100,000 Iowa 0.3% of the anticipated cost of the project; min $600; max $21,000 Kentucky 0.5 % of the capital expenditure; min $1,000; max $25,000 Louisiana $200 Maine 0.1% of capital expenditure; min $5,000; max $250,000 Massachusetts 0.2% of proposed capital expenditures; min $250 Michigan Based on Project cost: min $3,000; max $15,000 Mississippi 0.75% of proposed capital expenditure; min $1,250; max $75,000 Missouri 0.1% of the total project cost; min $1,000 Montana 0.3% of the capital expenditure; min $500 Nebraska $1,000 Nevada $9,500 New Hampshire 0.25% of the capital cost; min $500; max $12,000; Board also supported by administrative fee on all regulated entities collected annually New Jersey 0.25 % of Total Project Cost +$7,500 New York $2,000 + 0.55% of costs, or $2,000 + 0.3% of costs North Carolina $5,000 + 0.3% of capital expenditure; max $50,000 Ohio 1.5% of the capital expenditure; min $5,000; max $20,000 Oklahoma $3,000 Oregon Fee schedule based on costs; min $13,500; max $90,900 Rhode Island $500 + 0.25% of Capital Cost South Carolina $500 + 0.5% of the total project cost; max $7,000 (issuance fee of $7,500 required for projects of $1.4 million and greater) Tennessee 0.225% of capital expenditure; min $3,000; max $45,000 Vermont 0.125% of project costs; min $250; max $20,000 Virginia 1% of proposed expenditure; min $1,000, max $20,000 Washington Based on facility type, min $12,874; max $46,253 West Virginia 0.1% of capital expenditure; min $1,500; max $100,000

State by State: Application Fees State(s) Minimum Fee Vermont & Massachusetts $250 Montana & New Hampshire $500 Iowa $600 Virginia, Georgia, Kentucky & Missouri $1,000 Mississippi $1,250 West Virginia $1,500 Illinois $2,500 Michigan & Tennessee $3,000 D.C. Maine & Ohio $5,000 Florida $10,000 Washington $12,874 Oregon $13,500

State by State: Conditions 24 states permit conditional certificates 11 states do not have limitations set on what conditions can be placed on certificates Those states which do have restrictions on conditions usually have the following restrictions: The conditions must be related to the specific project The conditions must be related to the CON statute and regulations Virginia law is the most restrictive regarding conditions – prescribing which conditions may be used Alaska Can include specifying a minimum period during which an activity must be available in the proposed service area Delaware Conditions must be related to the specific project D.C. Conditions must be related to adopted review criteria Florida Permitted Hawaii Conditions must directly relate to established law; conditions are on application must be modified Illinois Conditions permitted Kentucky Conditions permitted including limitations regarding services or patients Maine Permitted Massachusetts Permitted; should be related to making health care services reasonably available to every person within the state at the lowest reasonable aggregate cost Michigan Permitted Montana Permitted must be related to elements prescribed by statute Nebraska Only permitted for long term care beds Nevada Permitted; must be directly related to the proposed project and to the criteria used for review New Hampshire Permitted; including the project amount, bed complement, patient charges, patient mix; other conditions. New Jersey Permitted; Must relate to material presented in the application, state regulations and/or promote the intent of the CON statute North Carolina Permitted; to be negotiated with applicant Ohio Permitted Oregon Permitted; must be directly related to the project and to review criteria placed in regulation Rhode Island Permitted; some set out in regulation South Carolina Permitted Tennessee Permitted Vermont Permitted Virginia Permitted; prescribed by regulation Washington Permitted; must be related to the project being reviewed and review criteria West Virginia Permitted; must be related to criteria found in the Statute and Regulations. Only permissible for 3 year.

State by State: Review Moratoria Alabama Moratoria on nursing homes and in-patient hospice beds Florida Moratorium for additional community nursing home beds lifted July 2014 Louisiana Moratorium on nursing homes Mississippi Moratorium on home health agencies and long term care facilities Nebraska Moratoria on nursing home and rehabilitation beds; certain exceptions New Hampshire Moratoria on nursing homes, skilled nursing facilities, intermediate care facilities and rehabilitation facilities. Rehabilitation beds.

State by State: Review Moratoria New Jersey, Virginia Long Term Care Applications are subject to the issuance of a call for applications Rhode Island Moratorium on Nursing facility beds

State by State: Monitoring 28 states require some form of monitoring after a certificate is issued 21 States require progress reports Some required quarterly Others due at specific benchmarks 10 States require annual reporting A majority of states require some form of financial and cost reporting 1 state requires all CON regulated facilities to report annually Alaska Annual expenditure; Development of project until completed Arkansas Progress report at construction, foundation, and ever 6 months until the project is licensed. Connecticut All hospitals are required to submit certain financial and statistical data annually D.C. Quarterly progress reports Florida Status report due after the first 15 months; Annual compliance reports for certificates with conditions. Georgia All CON regulated facilities must provide annual reports; CON holders must submit progress report within 12 months and after completion of each phase Hawaii Periodic reports as the agency requires Illinois Annual progress reports Iowa Progress reports required; first required six months after approval; Annual reporting required Kentucky Biennial review; Annual survey Maine Periodic reports must be submitted every 6 months, Cost and utilization reports every 6 months, & summary report when the service becomes operational. Maryland Quarterly progress reports beginning 3 months after certificate is issued Massachusetts Progress reports required for the first two years re: conditions Mississippi Progress reports every 6 months and at completion Missouri Progress reports every 6 months Montana Annual reports required Nevada Quarterly progress reports required New Hampshire Implementation reports required: 30 days after CON issued, semi-annually during development; annually after commencement New Jersey Progress reports required for CONs with conditions, at least 12 months from the date of approval and annually for the first 2 years after project implementation. North Carolina Progress Reports required Oklahoma Can be required by the Commissioner Rhode Island ProgOregon Progress reports once every three months; report on completion ress reports required at 6 month intervals South Carolina Monthly progress reports and a final completion report Vermont Reporting requirements placed on certificate Virginia Progress reports required on annually until completion of the project. Conditioned COPNs required to report compliance with condition annually. Washington Quarterly progress reports West Virginia Due 45 days prior to the expiration of the certificate

NO CON: State by State 15 states currently do not have a CON program: Arizona, California, Colorado, Idaho, Indiana, Kansas, Minnesota, New Mexico, North Dakota, Pennsylvania, South Dakota, Texas, Utah, Wisconsin, & Wyoming In 1987, the federal government repealed the CON mandate and throughout the 1980s, states began retiring their CON programs. By 1990 12 states repealed their CON program. By 2000 an additional 3 had repealed their programs. Since 2000, Wisconsin is the only state to repeal it’s program.

Questions?