Analysis of State CON Requirements Chart I Does CON apply to acquisition

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1 Alabama Alaska Arkansas To whom does CON apply? No person may acquire, conduct, or operate a new institutional facility ( NIF ) without first obtaining a CON. NIF means: (1) establishment of a new HCF; (2) purchase of MME; (3) offering a new health service. Health care facility includes hospitals, and related facilities such as, laboratories, out-patient clinics, and central service facilities operated in connection with hospitals;, and ASCs. A person cannot make an capital expenditure for $1,000,000 or more for any of the following: (1) construction of a HCF; (2) a HCF s adding a category of health services. HCFs defined to include hospitals, independent diagnostic testing facilities, and ASCs. Only applies to nursing facilities. $4,108,000 by or on behalf of a HCF. HCF construction project of at least $1,000,000. $500,000 for nursing homes only. Yes, for acquisitions of MME that is valued at least at $2,054,000. MME is defined as medical equipment used for diagnosis or treatment of medical conditions by a HCF. Yes, if purchased by a HCF and valued at least at $1,000,000. No. Yes, with no monetary threshold. Health services are diagnostic, curative, or rehabilitative services, furnished on either an in-patient or out-patient basis by HCFs. Health services includes: (1) cardiac cath. Services; (2) gamma knife services; (3) radiation therapy; (4) and ultrasound. Yes, applies to addition of a category of health services by a HCF if cost of doing so is at least $1,000,000. Category of health services" includes: (1) cardiac cath. services; (2) CT scans; (3) gamma knife procedures; (4) lithotripsy services; (5) PET scans; (6) radiation therapy; (7) ultra-sound. No. Abbreviations: HCF means health care facility; MME means major medical equipment. 1

2 Connecticut Delaware To whom does CON apply? CON applies to any HCF or institution: (1) proposing a capital expenditure exceeding $1,000,000; or (2) proposing the acquisition of MME requiring a capital expenditure in excess of $400,000. "Health care facility or institution" includes: (1) outpatient clinics; (2) outpatient surgical facilities; (3) imaging centers; (4) diagnostic and treatment facilities. A person must obtain a certificate of public review prior to undertaking: (1) a capital expenditure by, or on behalf of, a HCF if that expenditure exceeds $5,000,000; and (2) the acquisition of MME, whether or not by a health care facility, in excess of $5,000,000. HCF includes a hospital and ASC. (1) For health facility construction, renovation etc., $1,000,000. Capital expenditure by, or on behalf of, a HCF if that expenditure exceeds $5,000,000. But does not apply to construction of medical office building. (2) Any proposed purchase, lease, or other acquisition of MME is subject to CON, regardless of the value of the MME. (S.B. 1207, enacted in 2005). Yes, if valued in excess of $5,000,000. Applies not just to purchase by HCFs, but to anyone making the purchase of MME. Any new health service proposed to be offered by a health care facility or institution requires a prior CON. Covered health services include: (1) cardiac cath. services; (2) gamma knife procedures; (3) PET scans; (4) MRI; (5) radiation therapy; (6) ultra-sound. No monetary threshold, but a person must obtain a CON prior to offering the following services: (1) cardiac cath. services; (2) lithotripsy services; (3) PET scans; (4) radiation therapy. 2

3 District of Columbia Florida Georgia 1 To whom does CON apply? Any person must obtain a CON prior to: (1) establishing a new HCF; (2) establishing a new health care service; (3) making a capital expenditure. HCF includes a general/specialty hospital, ambulatory care center, ASC, diagnostic health care facility, or other comparable health care facility which has an annual operating budget of at least $500,000. Applies to health care facilities, defined only to include hospitals, skilled nursing facilities, hospice, or intermediate care facility for the developmentally disabled. Anyone proposing to offer a new institutional health service must obtain a CON prior to doing so. New institutional health service includes: (1) the establishment of a new HCF; (2) a capital expenditure by or on behalf of a HCF in excess of $1,322,451; (3) a HCF offering a new clinical health service; (4) a HCF acquiring diagnostic or therapeutic equipment valued in excess of $734,695; (5) specific new clinical health services offered through a diagnostic, treatment, or rehabilitation center. 2 $2,500,000 for construction of a new HCF. Yes. Capital threshold depends on whom is making the acquisition. (1) If MME is being purchased by a facility of a private group practice of diagnostic radiology or radiation therapy, threshold is excess of $1,500,000. (2) If a single piece of diagnostic or therapeutic equipment is acquired by a physician or group of physicians (excluding those referenced in (1) above, the threshold is an excess of $250,000. Any person must obtain a CON prior to offering a new health care service, so long as the expenditure for offering the service exceeds $600,000. A health service" includes: (1) cardiac cath. services; (2) CT scans; (3) gamma knife procedures; (4) lithotripsy services; (5) MRI; (6) PET scans; (7) radiation therapy. None. None. Yes, with no monetary threshold. 1. $1,322,451 by, or on behalf of, a HCF. 2. For the development of a limited-purpose, physician-owned ASC, $1,436,356. (See Chart II for more information). The threshold for (1) acquisition of diagnostic or therapeutic equipment by a HCF; or (2) a diagnostic, therapeutic, or rehabilitation center s acquisition of diagnostic or therapeutic equipment is $734,695 for both cases. Yes, but two categories apply. (1) A CON is required prior to a HCF offering a new clinical health service, and no monetary threshold applies. In this instance, clinical health services is defined to include: (1) MRI (2) PET scans; (3) radiation therapy; (4) biliary lithotripsy services; (5) surgery; (6) cardiac cath. services.; (7) CT scans; (8) gamma knife services. (2) A CON is required prior to a diagnostic, therapeutic, or rehabilitation center offering a new clinical health service, and no monetary threshold applies. In this instance, clinical health services is defined to include: (1) radiation therapy; (2) biliary lithotripsy; (3) surgery in an operating room environment, including an ASC (but see Chart II for a physician exception); and (4) cardiac cath. 3

4 Hawaii To whom does CON apply? No person may perform the following without first obtaining a CON: (1) constructing or modifying a HCF or existing health care service if doing so involves a capital expenditure over $4,000,000; (2) acquiring new MME costing over $1,000,000; (3) acquiring used MME costing over $400,000; or (4) establishing a new health care service, regardless of expenditure amount. Threshold for capital of Major Medical Equipment? expenditure? Threshold? $4,000,000 for capital expenditures for developing a HCF. Yes, $1,000,000 for new or replacement MME; $400,000 for used MME. Does CON apply to the development of a new Yes, any person seeking to offer a new health care service" must first obtain a CON, regardless of monetary outlay. Health care service includes: (1) CT scans; (2) gamma knife procedures; (3) lithotripsy services; (4) MRI; (5) PET scans; (6) radiation therapy. (7) cardiac cath. services. Illinois A person must obtain a CON prior to: (1) constructive/modification of a HCF where cost involves a capital expenditure exceeding $6,732,798; (2) purchase of MME where cost exceeds $6,425,245; (3) effecting substantial changes in the scope or operation of a health care facility, e.g., adding a new health service covered by CON. Construction/modification health care facility involving capital expenditure exceeding $6,732,798. Yes, if cost is in excess of $6,425,245. However, the CON statute states that the acquisition by any person of MME that will not be owned by or located in a health care facility and that will not be used to provide services to inpatients of a health care facility shall be exempt from review. A HCF must obtain a CON prior to adding new health care services. No monetary threshold has to be satisfied. Covered services include: cardiac cath. services. 4

5 Iowa Kentucky To whom does CON apply? No person can develop a new institutional health service ( NIHS ) without obtaining a CON. NIHS includes: (1) the development of a new HCF; (2) any capital expenditure by a HCF in excess of $1,500,000; (3) any expenditure in excess of $500,000 by a HCF to develop a new health service; (4) any acquisition by a I or HCF of MME valued in excess of $1,500,000. HCF includes: a hospital, a health care facility, an organized outpatient health facility, an outpatient surgical facility. A person must obtain a CON prior to: (1) establishing a HCF; (2) obligating a capital expenditure which exceeds the capital expenditure minimum of $1,951,612; (3) making a substantial change in a health service; and (4) acquiring MME. HCF means any institution, place, or building designed to provide medical diagnosis, treatment, nursing, rehabilitative, or preventive care, including, hospitals, outpatient clinics, ambulatory care facilities, ambulatory surgical centers. Threshold for capital of Major Medical Equipment? expenditure? Threshold? Any capital expenditure by a health facility in excess of $1,500,000. Capital expenditure by or on behalf of a HCF is in excess of $1,951,612 until June 30, $1,500,000 threshold applies to purchases of MME by a HCF, health care provider, or group of health care providers, e.g., medical practice. Yes, CON is triggered when costs of MME exceed $1,951,612. Does CON apply to the development of a new Yes, so long as the expenditure is by a HCF and is in excess of $500,000. Services subject to CON under this $500,000 threshold include: (1) cardia cath. services; (2) PET scans; (3) and radiation therapy. Yes, when a person makes a substantial change in a health service. Health service includes: (1) cardiac cath. services; (2) lithotripsy services; (3) MRI; (4) radiation therapy. 5

6 Louisiana Maine 3 Maryland To whom does CON apply? Only applies to nursing facilities and ICF-MRs. A person may not engage in the following activities without obtaining a CON: (1) establishing a new HCF; (2) acquiring MME; (3) a capital expenditure of $2,400,000 or more by or on behalf of a HCF; (4) offering a new health service. HCF is defined to include hospitals, ASCs, independent radiological service centers, independent cardiac catheterization centers, and cancer treatment centers. A person must obtain a CON prior to: (1) establishing a new health facility; (2) changing a health care facility s type or scope of any health care service; (3) a health care facility s engaging in a capital expenditure in excess of $1.55 million. HCF includes hospitals, a limited service hospitals, and ASCs. Threshold for capital of Major Medical Equipment? expenditure? Threshold? Does CON apply to the development of a new No. No. Any new long-term care service provided by a nursing facility or new mental retardation service provided by an ICF-MR. Capital threshold by or on behalf of a HCF is $2,400,000. A capital expenditure by or on behalf of a HCF in excess of $1,550,000. Yes, a CON is required for any purchase of MME valued in excess of $1,200,000. No. Yes, addition of a new health care service by, or on behalf of, a HCF, where the capital expenditure of adding the service exceeds $110,000 in capital expenditures or that have new 3 rd -year operating costs of $400,000 or more. Health service includes: (1) cardiac cath. services; (2) CT scans; (3) MRI; (4) PET scans; (5) radiation therapy; (6) ultra-sound. A certificate of need is required whenever a health care facility changes the type or scope of a health care service. No monetary threshold. Health care services subject to CON include: (1) cardiac cath. services, except that diagnostic-only cardiac cath. services are not subject to CON. 6

7 Massachusetts Michigan To whom does CON apply? A person may not engage in the following without first obtaining a CON: (1) a capital expenditure to construct a health care facility; (2) a HCF s substantially changing a health service; (3) or acquisition of various types of MME. A person wanting to perform the following cannot do so without first obtaining a CON: (1) operate a new HCF; (2) initiate/expand a covered clinical service; or (3) make a covered capital expenditure. HCF includes a hospital, nursing home, and ASC. Threshold for capital expenditure? 1. For acute-care hospitals and comprehensive cancer centers $12,004,549; 2. for non-acute care facilities and clinics, $1,280,485. of Major Medical Equipment? Threshold? 1. If major moveable equipment is being acquired by non-acute care facilities and clinics: $640,242. Major moveable equipment is equipment not permanently attached to the building and that has a depreciable life of three or more years. 2. No person may provide an innovative service or use a new technology, in any location other than in a health care facility, without first obtaining a CON. (A) New technology includes MRIs, PET, lithotrypters, and linear accelerators, intended for use in medical/surgical services. (B) "Innovative service", includes such services as dialysis, transplant services, cardiac catheterization, angioplasty and neonatal intensive care. $2,665,000. CON requirements do not explicitly apply to the purchase of MME. However, purchase of MME could require a CON since purchase of most MME will involve the development of a covered clinical service (CCS) which requires a CON before development. (See column immediately to the right). Does CON apply to the development of a new A health care facility cannot add a new health service without satisfying CON requirements, regardless of monetary expenditure. Covered health care services include: (1) gamma knive services; (2) lithotripsy services; (3) MRI; (4) PET; (5) radiation therapy. Yes, because the addition or development of any covered clinical service requires a CON. A CCS is defined to include: (i) lithotripsy services; (ii) megavoltage radiation therapy services, (iii) PET scans; (iv) surgical services provided in an ASC; (v) cardiac cath. services; (vi) MRI, and (vii) CT. No monetary threshold. 7

8 To whom does CON apply? Mississippi No person can engage in the following without obtaining a CON: 1. creation of a new health care facility; 2. creation of covered clinical services; 3. engaging in a capital expenditure; or 4. acquisition of MME. HCF includes hospitals and ASCs. Missouri Any person proposing to: 1. develop a HCF; 2. acquire MME; 3. offer a new health service; or 4. engage in a capital expenditure, must first obtain a CON. A HCF is defined to include: hospitals; diagnostic imaging centers, radiation therapy centers and ASCs. Montana No person can engage in the following without a CON: 1. establishing a new HCF; 2. a HCF offering a new health care service; 3. capital expenditure by/on behalf of a HCF. A HCF is defined as a home health agency, nursing home, inpatient chem. dependency facility, and, in some specific cases includes ASCs. Nebraska Applies only to long-term care facilities. $2,000, 000. Yes. The capital expenditure threshold for MME is $1,500,000. A CON is required before any person may provide the following services, regardless of expenditure amount: (i) cardiac cath services; (c) radiation therapy services; (d) diagnostic imaging services of an invasive nature; (e) MRI; (f) lithotripsy services; (g) PET scans. Set at $1,000,000. Yes, threshold is $1,000,000. Yes, if the new health service is offered in a HCF and involves an expenditure exceeding $1,000,000. Covered health services include: (1) cardia cath. services; (2) CT scans; (3) gamma knife procedures; (4) PET scans; (5) radiation therapy. $1,500,000. No. Yes, if cost of service exceeds $150,000. For the purposes of this chart, the only relevant services are ambulatory surgical services. CON only applies to ambulatory surgical services under very specific conditions. No. No. No. 8

9 Nevada New Hampshire New Jersey To whom does CON apply? Unless the person is located in a county with a population of 100,000 or more, no person can engage in a HCF construction project without a CON. A HCF is any facility that provides for care, observation, and diagnosis of patients. No person can engage in the following without a CON: 1. construction of an acute care facility, ASC, or specialty hospital exceeding the applicable capital expenditure; 2. acquisition by health care provider of MME; 3. offering a new inpatient health service. No HCF or health service can be established without first obtaining a CON. A HCF is a facility providing diagnosis or treatment of human disease, or physical condition, including, a general or special hospital, diagnostic center, outpatient clinic. $2,000,000 No. No. 1. For acute care facilities: $1,952, For ASCs and specialty hospitals, $1,301,914. $2,000,000 to construct a new HCF. Yes, for acquisition of equipment valued in excess of $400,000. Yes, CON applies to any person s purchase of new MME costing over $2,000,000. (Replacement of existing major moveable equipment does not require a CON). CON required before offering any new inpatient service, regardless of monetary threshold. Covered services include: (1) ambulatory surgical services; (2) CT services; (3) lithotripsy services; (4) MRI; (5) PET scans; (6) radiation therapy. Yes, with no monetary threshold. "Health care service" includes cardiac cath. services. 9

10 New York North Carolina Ohio Oklahoma To whom does CON apply? CON requirements also apply to: (1) addition of a new service by a medical facility; (2) a medical facility s acquisition of a new MME; (3) any medical facility construction project, the total cost of which exceeds $3,000,000; (4) the establishment of a medical facility. Medical facilities includes hospitals and diagnostic and treatment centers. No person can perform the following without a CON: (1) develop a new Health Service Facility HSF ; (2) engage in any capital expenditure by/on behalf of a HSF ; (3) creation of a new health service; (4) acquisition of MME; (5) the conversion of a specialty ambulatory surgical program to a multispecialty ambulatory surgical program; or (6) the addition of a specialty to a specialty ambulatory surgical program. HSF includes: (1) hospitals; (2) diagnostic centers; (3) ASCs; and (4) oncology centers. Applies only to long-term care facilities. Applies only to nursing facilities and hospital-based skilled nursing units. Yes, any construction project that exceeds $3,000,000 in costs. Capital expenditure $2,000,000. $3,000,000 Yes, with no capital threshold. A medical facility, e.g., diagnostic centers and treatment centers must obtain a CON prior to commencing the following services: (1) therapeutic radiology; (2) cardiac cath. services; (3) MRI; (4) CT scans; (5) lithotripsy services; (6) PET scans; (7) gamma knife procedures; (8) ultrasound. Yes, for the following MME, so long as the value of the equipment to be acquired exceeds $750,000: (1) cardiac angioplasty equipment; (2) cardiac cath. equipment; (3) gamma knives; (4) lithotriptors. 7. MRI; 8. PET. Yes, a person proposing to offer health services must first obtain a CON. Health services includes: (1) cardiac cath. services; (2) gamma knife services; (3) lithotripsy services; (4) MRI; (5) radiation therapy; (6) PET services. No monetary threshold. $2,000,000 No. Yes, change in long-term care services offered. $1,000,000. No. Increasing the number of beds at an existing nursing facility of hospital-based SNF. 10

11 Oregon Rhode Island South Carolina To whom does CON apply? A person proposing to establish a new hospital or nursing facility cannot do so without first obtaining a CON. The following require a CON: (1) a health care provider s purchase of MME exceeding the specified threshold; (2) construction of a new HCF; (3) a capital expenditure by a HCF; 4. a HCF offering a new health service. A person or HCF must obtain a CON prior to engaging in the following: 1. development of a new HCF; 2. a capital expenditure by/on behalf of a HCF; 3. addition of a new health service; 4. acquisition of MME. A HCF includes hospitals and ASCs. None. None. Yes, any new service proposed to be offered by a hospital or nursing facility. No monetary threshold. $2,000,000 Yes, threshold at $1,000,000. A HCF cannot offer a new health service if the cost of adding that service exceeds $750,000. "Health services" covered under CON include: (1) cardiac cath. services; (2) CT scans; (3) gamma knife services; (4) MRI; (5) PET scans; and (6) radiation therapy. $2,000,000 Yes, so long as the acquisition cost is in excess of $600,000. Yes, a HCF must first obtain a CON if it wishes to establish a new health service, so long as the cost of adding that service exceeds $1,000,000. Health services covered by CON include: (1) cardiac cath. services; (2) CT scans; (3) gamma knife services; (4) lithotripsy services; (5) MRI; (6) PET scans; (7) radiation therapy. Tennessee No person may perform the following without a CON: 1. development of a new HCF; 2. adding a new health service; 3. acquisition of MME; 4. engaging in a capital expenditure. 1. For hospitals: $5,000, For HCFs that are not hospitals: $2,000,000. Yes, if the value of the MME to be acquired exceeds $1,500,000. Yes, a person must obtain a CON prior to initiating certain health services, which include: (1) extracorporeal lithotripsy services; (2) MRI; (3) cardiac cath. services; (4) linear accelerator services; (4) PET scans; (5) outpatient surgery; (6) radiation therapy. 11

12 Vermont Virginia To whom does CON apply? A person must obtain a CON prior to: 1. the establishment of a HCF; 2. a capital expenditure; 3. the acquisition of MME; 4. a new service offered by a HCF. A HCF includes: hospitals; outpatient diagnostic or therapy programs; diagnostic imaging facilities, independent diagnostic laboratories, cardiac catheterization laboratories, radiation therapy facilities. A person cannot commence a project without first obtaining a CON. A project includes: (1) the establishment of a medical care facility ( MCF ); (2) the introduction of a new service into a MCF; (3) an MCF s acquisition of MME; or (4) a capital expenditure. MCF includes: (1) hospitals; and (2) specialized centers or clinics or that portion of a physician's office developed for the provision of: (a) outpatient or ambulatory surgery; (b) cardiac catheterization: (c) CT scanning; (d) gamma knife surgery; (e) lithotripsy; (f) MRI; (g) magnetic source imaging (MSI); (h) PET; (i) radiation therapy; (j) nuclear medicine imaging. 1. For hospitals, threshold is excess of $3,000, For other HCFs, excess of $1,500,000. Yes, if cost of MME is in excess of $1,000,000. $5,000,000 or more Yes. MCF must obtain a CON prior to acquiring any of the following, regardless of cost: (1) equipment for the provision of cardiac catheterization; (2) CT scanning; (3) gamma knife surgery; (4) lithotripsy; (5) MRI; (6) magnetic source imaging (MSI), (7) PET scanning, (8) radiation therapy, or other specialized service designated by the State of Virginia by regulation. Yes, a HCF must obtain a CON prior to offering a new health service, so long as the annual operating expense of the new health service exceeds $500,000. Health service includes: (1) cardiac cath. services; (2) CT scans; (3) gamma knife services; (4) lithotripsy services; (5) MRI; (6) PET scans; (7) radiation therapy. Yes, an MCF must obtain a CON prior to adding any of the following services: (1) cardiac cath. services; (2) CT scanning; (3) gamma knife surgery; (4) lithotripsy services; (5) MRI; (6) magnetic source imaging; (7) PET scanning; (8) radiation therapy, (9) nuclear medicine imaging; or (10) such other specialty clinical services as may be designated by the State of Virginia by regulation. 12

13 To whom does CON apply? Washington 4 No person can engage in the following without a CON: 1. development of a new HCF, i.e., ASC or hospital; 2. capital expenditure (applies only to nursing homes); 3. new tertiary health services. HCF includes hospitals and ASCs West All health care providers must Virginia obtain a CON before: 1. adding a new service; 2. engaging in a capital expenditure exceeding the capital threshold; 3. obtaining MME; or 4. developing new HCFs. Health care facility means hospitals, ambulatory health care facilities, ASCs. Wisconsin Applies only to nursing homes. $1,000,000, but applies only to nursing homes. $1,200,000, but applies No. Yes, any time a health care facility adds a new tertiary only to nursing facilities. health service. $2,000,000. Yes, with the CON threshold set at $2,000,000. Yes, set at $600,000, but applies only to nursing homes. Yes, a HCF cannot offer new health services without first obtaining a CON. No monetary threshold applies. Health services includes: (1) surgical services; (2) cardiac cath. services; (3) lithotripsy services; (4) MRI; (5) radiation therapy; (6) PET. Yes, any time a long term care facility wants to add a new service. 1 In 2005, the Georgia enacted H.B. 390, which creates the State Commission on the Efficacy of the Certificate of Need Program. The Commission will study the state s CON program and render a final report on the CON program s ability to meet its intended goals, and whether the Georgia CON program should continue. 2 In 2005, Maine enacted L.D. 16. L.D. 16 establishes a 90-day period for review and decision on a completed certificate of need application and provides for issuance of the certificate of need if the Commissioner of Health and Human Services does not meet the 90-day requirement. 3 In 2005, the State of Washington enacted H.B. 1688, which creates a CON task force. The purpose of the task force is to study and prepare recommendations to the Washington Governor and the legislature related to improving and updating Washington s CON program. The task force will evaluate the scope of facilities, services, and capital expenditures that should be subject to CON review. The task force must submit its report to the governor and appropriate committees of the Washington Legislature by November 1,