HomeMy WebLinkAboutAgreement A-22-097 with DHCS.pdf Agreement No. 22-097
STATE OF CALIFORNIA-DEPARTMENT OF GENERAL SERVICES SCO ID:4260-1794581-Al
STANDARD AGREEMENT-AMENDMENT
STD 213A(Rev.4/2020) AGREEMENT NUMBER AMENDMENT NUMBER Purchasing Authority Number
® CHECK HERE IF ADDITIONAL PAGES ARE ATTACHED 148 PAGES 17-94581 A01
1.This Agreement is entered into between the Contracting Agency and the Contractor named below:
CONTRACTING AGENCY NAME
Department of Health Care Services
CONTRACTOR NAME
County of Fresno
2.The term of this Agreement is:
START DATE
July 1,2017
THROUGH END DATE
June 30,2022
3.The maximum amount of this Agreement after this Amendment is:
$0.00(Zero Dollars)
4.The parties mutually agree to this amendment as follows.All actions noted below are by this reference made a part of the Agreement and
incorporated herein:
I. The effective date of this amendment is the date approved by DHCS.
II.Purpose of Amendment:Updating terms and conditions to comply with federal regulations as determined by the Centers for Medicare and Medicaid
Services.
(Continued on next pages)
All other terms and conditions shall remain the same.
ATTEST:
IN WITNESSWHEREOF,THIS AGREEMENTHAS BEEN EXECUTED BY THE PAR TIES HER ETO. BERNICE E.SEIDEL
CONTRACTOR Clerk of the Board of Supervisors
County of Fresno,State of California
CONTRACTOR NAME(if other than an individual,state whether a corporation,partnership,etc.) By
County of Fresno Deputy
CONTRACTOR BUSINESS ADDRESS CITY STATE ZIP
1925 E Dakota Ave Fresno CA 93726
PRINTED NAME OF PERSON SIGNING TITLE
Brian Pacheco Chairman of the Board of Supervisors of the County of Fresno
CONTRACTOR TH IZED SIGNATURE DATE SIGNED
1 .. ,�... 3
STATE OF CALIFORNIA
CONTRACTING AGENCY NAME
Department of Health Care Services
CONTRACTING AGENCY ADDRESS CITY STATE ZIP
1501 Capitol Avenue MS 4200 Sacramento CA 95814
PRINTED NAME OF PERSA1-2C-J
SIGNING TITLE \ z
Aq1 Afo�
CONTRACTING AGENCY AUT ORI ED SIGNATURE DATE SIGNE
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44W Pq
CALIFORNIA DEPARTMENT OF ENERAL SERVICES APPROVAL EXEMPTION(If plicab )
Exempt per:WIC 14703
Page 1 of 1
County of Fresno
17-94581 A01
Continuation of STD 213A
III. Certain changes made in this amendment are shown as: Text additions are
displayed in bold and underline (i.e. bold and underline). Text deletions are
displayed as strike through text (i.e. mike).
IV. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A Al - Scope of Work (2 pages)
All references to Exhibit A — Scope of Work, in any exhibit incorporated into this
agreement shall hereinafter be deemed to read Exhibit A Al - Scope of Work.
The attached revised exhibit hereby replaces Exhibit A— Scope of Work.
V. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 1 Al — Organization and Administration (6 pages)
All references to Exhibit A, Attachment 1 — Organization and Administration, in
any exhibit incorporated into this agreement shall hereinafter be deemed to read
Exhibit A, Attachment 1 Al - Organization and Administration. The attached
revised exhibit hereby replaces Exhibit A, Attachment 1 — Organization and
Administration.
VI. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 2 Al — Scope of Services (10 pages)
All references to Exhibit A, Attachment 2 — Scope of Services, in any exhibit
incorporated into this agreement shall hereinafter be deemed to read Exhibit A,
Attachment 2 Al - Scope of Services. The attached revised exhibit hereby
replaces Exhibit A, Attachment 2 — Scope of Services.
VII. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 3 Al — Financial Requirements (7 pages)
All references to Exhibit A, Attachment 3 — Financial Requirements, in any exhibit
incorporated into this agreement shall hereinafter be deemed to read Exhibit A,
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County of Fresno
17-94581 A01
Continuation of STD 213A
Attachment 3 Al - Financial Requirements. The attached revised exhibit hereby
replaces Exhibit A, Attachment 3 — Financial Requirements.
VIII. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 4 Al — Management Information Systems (2 pages)
All references to Exhibit A, Attachment 4 — Management Information Systems, in
any exhibit incorporated into this agreement shall hereinafter be deemed to read
Exhibit A, Attachment 4 Al - Management Information Systems. The attached
revised exhibit hereby replaces Exhibit A, Attachment 4 — Management
Information Systems.
IX. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 5 Al — Quality Improvement System (6 pages)
All references to Exhibit A, Attachment 5 — Quality Improvement System, in any
exhibit incorporated into this agreement shall hereinafter be deemed to read
Exhibit A, Attachment 5 Al - Quality Improvement System. The attached revised
exhibit hereby replaces Exhibit A, Attachment 5 — Quality Improvement System.
X. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 6 Al — Utilization Management Program (4 pages)
All references to Exhibit A, Attachment 6 — Utilization Management Program, in
any exhibit incorporated into this agreement shall hereinafter be deemed to read
Exhibit A, Attachment 6 Al - Utilization Management Program. The attached
revised exhibit hereby replaces Exhibit A, Attachment 6 — Utilization
Management Program.
XI. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 7 Al — Access and Availability of Services (6 pages)
All references to Exhibit A, Attachment 7 —Access and Availability of Services, in
any exhibit incorporated into this agreement shall hereinafter be deemed to read
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County of Fresno
17-94581 A01
Continuation of STD 213A
Exhibit A, Attachment 7 Al - Access and Availability of Services. The attached
revised exhibit hereby replaces Exhibit A, Attachment 7 — Access and Availability
of Services.
XII. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 8 Al — Provider Network (12 pages)
All references to Exhibit A, Attachment 8 — Provider Network, in any exhibit
incorporated into this agreement shall hereinafter be deemed to read Exhibit A,
Attachment 8 Al - Provider Network. The attached revised exhibit hereby
replaces Exhibit A, Attachment 8 — Provider Network.
XIII. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 9 Al — Documentation Requirements (7 pages)
All references to Exhibit A, Attachment 9 — Documentation Requirements, in any
exhibit incorporated into this agreement shall hereinafter be deemed to read
Exhibit A, Attachment 9 Al - Documentation Requirements. The attached revised
exhibit hereby replaces Exhibit A, Attachment 9 — Documentation Requirements.
XIV. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 10 Al — Coordination and Continuity of Care (2 pages)
All references to Exhibit A, Attachment 10 — Coordination and Continuity of Care,
in any exhibit incorporated into this agreement shall hereinafter be deemed to
read Exhibit A, Attachment 10 Al - Coordination and Continuity of Care. The
attached revised exhibit hereby replaces Exhibit A, Attachment 10 — Coordination
and Continuity of Care.
XV. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 11 Al — Information Requirements (13 pages)
All references to Exhibit A, Attachment 11 — Information Requirements, in any
exhibit incorporated into this agreement shall hereinafter be deemed to read
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County of Fresno
17-94581 A01
Continuation of STD 213A
Exhibit A, Attachment 11 Al - Information Requirements. The attached revised
exhibit hereby replaces Exhibit A, Attachment 11 — Information Requirements.
XVI. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 12 Al — Beneficiary Problem Resolution (23 pages)
All references to Exhibit A, Attachment 12 — Beneficiary Problem Resolution, in
any exhibit incorporated into this agreement shall hereinafter be deemed to read
Exhibit A, Attachment 12 Al - Beneficiary Problem Resolution. The attached
revised exhibit hereby replaces Exhibit A, Attachment 12 — Beneficiary Problem
Resolution.
XVII. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 13 Al — Program Integrity (7 pages)
All references to Exhibit A, Attachment 13 — Program Integrity, in any exhibit
incorporated into this agreement shall hereinafter be deemed to read Exhibit A,
Attachment 13 Al - Program Integrity. The attached revised exhibit hereby
replaces Exhibit A, Attachment 13 — Program Integrity.
XVIII. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit A, Attachment 14 Al — Reporting Requirements (3 pages)
All references to Exhibit A, Attachment 14 — Reporting Requirements, in any
exhibit incorporated into this agreement shall hereinafter be deemed to read
Exhibit A, Attachment 14 Al - Reporting Requirements. The attached revised
exhibit hereby replaces Exhibit A, Attachment 14 — Reporting Requirements.
XIX. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit B Al — Budget Detail and Payment Provisions (5 pages)
All references to Exhibit B — Budget Detail and Payment Provisions, in any
exhibit incorporated into this agreement shall hereinafter be deemed to read
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County of Fresno
17-94581 A01
Continuation of STD 213A
Exhibit B Al - Budget Detail and Payment Provisions. The attached revised
exhibit hereby replaces Exhibit B — Budget Detail and Payment Provisions.
XX. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit E Al — Additional Provisions (17 pages)
All references to Exhibit E — Additional Provisions, in any exhibit incorporated into
this agreement shall hereinafter be deemed to read Exhibit E Al - Additional
Provisions. The attached revised exhibit hereby replaces Exhibit E —Additional
Provisions.
XXI. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit E, Attachment 1 Al — Definitions (5 pages)
All references to Exhibit E, Attachment 1 — Definitions, in any exhibit incorporated
into this agreement shall hereinafter be deemed to read Exhibit E, Attachment 1
Al - Definitions. The attached revised exhibit hereby replaces Exhibit E,
Attachment 1 — Definitions.
XXII. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following revised exhibit:
Exhibit E, Attachment 2 Al — Service Definitions (6 pages)
All references to Exhibit E, Attachment 2 — Service Definitions, in any exhibit
incorporated into this agreement shall hereinafter be deemed to read Exhibit E,
Attachment 2 Al — Service Definitions. The attached revised exhibit hereby
replaces Exhibit E, Attachment 2 — Service Definitions.
XXI I I. All other terms and conditions shall remain the same.
Page 6 of 6
County of Fresno
17-94581 A01
Page 1 of 2
Exhibit A Al
SCOPE OF WORK
1. Service Overview
Contractor agrees to provide to the California Department of Health Care
Services (DHCS) the services described herein.
The Contractor will provide or arrange for the provision of specialty mental health
services to eligible Medi-Cal beneficiaries of Fresno County within the scope of
services defined in this contract.
2. Service Location
The services shall be performed at all contracting and participating facilities of
the Contractor.
3. Service Hours
The services shall be provided on a 24-hour, seven (7) days a week basis.
4. Project Representatives
A. The project representatives during the term of this contract will be:
Department of Health Care County of Fresno
Services Susan Holt, Interim Director
Erika Cristo Telephone: 559-600-9180
Telephone: (916) 713-8546 Fax: 559-600-7905
Email: Erika.Cristo(Wdhcs.ca.aov Email: sholt@fresnocountyca.gov
B. Direct all inquiries to:
Department of Health Care County of Fresno
Services Attention: Joseph Rangel,
Division Manager
Medi-Cal Behavioral Health Division 1925 E. Dakota Ave.
Attention: Dee Taylor Fresno, CA 93726
1501 Capitol Avenue, MS 2702 Telephone: 559-600-6055
Sacramento, CA, 95814 Fax: 559-600-6089
Telephone: (916) 713-8509 Email:
Email: Dee.Taylor(@dhcs.ca.aov rangeja(a-).fresnocountyca.gov
C. Either party may make changes to the information above by giving written
notice to the other party. Said changes shall not require an amendment to
this contract.
County of Fresno
17-94581 A01
Page 2 of 2
Exhibit A Al
SCOPE OF WORK
5. General Authority
This Contract is entered into in accordance with the Welfare and Institutions
(Welf. & Inst.) Code § 14680 through §147267. Welf. & Inst. Code § 14712
directs the California Department of Health Care Services (Department) to
implement and administer Managed Mental Health Care for Medi-Cal eligible
residents of this state through contracts with mental health plans. The
Department and County of Fresno agrees to operate the Mental Health Plan
(MHP) for Fresno County. No provision of this contract is intended to obviate or
waive any requirements of applicable law or regulation, in particular, the
provisions noted above. In the event a provision of this contract is open to
varying interpretations, the contract provision shall be interpreted in a manner
that is consistent with applicable law and regulation.
6. AmermGans with Disabilities AGt Electronic and IT Accessibility
Requirements Under the Rehabilitation Act of 1973 and the Americans with
Disabilities Act of 1990
Contractor agrees to ensure that deliverables developed and produced pursuant
to this Agreement shall comply with the accessibility requirements of Sections
7405 and 11135 of the California Government Code, Section 508 of the
Rehabilitation Act of 1973 ` Rd the AmeFiGaRS with [Disabilities ^Gt of 197-9 as
amended (29 U.S.C. § 7944d)), and regulations implementing that Act as set
forth in Part 1194 of Title 36 of the Code of Federal Regulations (C.F.R.), and
the portions of the Americans with Disabilities Act of 1990 related to
electronic and IT accessibility requirements and implementing regulations
(42 U.S.C. § 12101 et seg.). In 1998, Congress amended the Rehabilitation Act
of 1973 to require Federal agencies to make their electronic and information
technology (EIT) accessible to people with disabilities. California Government
Code sections 7405 and 11135 codifies section 508 of the Act requiring
accessibility of electronic and information technology.
7. Services to be Performed
See Exhibit A, Attachments 1 through 14 for a detailed description of the services
to be performed.
County of Fresno
17-94581 A01
Page 1 of 6
Exhibit A—Attachment 1 Al
ORGANIZATION AND ADMINISTRATION
1. Implementation Plan
The Contractor shall comply with the provisions of the Contractor's
Implementation Plan as approved by the Department, including the
administration of beneficiary problem resolution processes. (California Code of
Regulations lCal. Code Regs.1 Title tit.1 9, §§ 1810.310, 1850.205-1850.208.)
The Contractor shall obtain written approval by the Department prior to making
any changes to the Implementation Plan as approved by the Department. The
Contractor may implement the changes if the Department does not respond in
writing within thirty calendar (30) days. (Cal. Code Regs. tit. 9, § 1810.310(c)(5).)
2. Prohibited Affiliations
A. The Contractor shall not knowingly have any prohibited type of
relationship with the following:
1) An individual or entity that is debarred, suspended, or otherwise
excluded from participating in procurement activities under the
Federal Acquisition Regulation or from participating in non-
procurement activities under regulations issued under Executive
Order No. 12549 or under guidelines implementing Executive Order
No. 12549. (42 C.F.R. § 438.610(a)(1).)
2) An individual or entity who is an affiliate, as defined in the Federal
Acquisition Regulation at 48 C.F.R. 2.101, of a person described in
this section. (42 C.F.R. § 438.610(a)(2).)
B. The Contractor shall not have a prohibited type of relationship by
employing or contracting with providers or other individuals and entities
excluded from participation in federal health care programs (as defined in
section 112813(f) of the Social Security Act) under either Section 1128 (42
U.S.C. 1320a-7), 1128A (42 U.S.C. 1320a-7a), 1156 (42 U.S.C. 1320c-5),
or 18420)(2) (42 U.S.C. § 1395u(j)(2)) of the Social Security Act. (42
C.F.R. §§ 438.214(d)(1), 438.610(b); 42 U.S.G. § 13220E )
C. The Contractor shall not have types of relationships prohibited by this
section with an excluded, debarred, or suspended individual, provider, or
entity as follows:
1) A director, officer, agent, managing employee, or partner of the
Contractor. (42 U.S.C. § 1320a-7(b)(8)(A)(ii); 42 C.F.R. §
438.610(c)(1).)
County of Fresno
17-94581 A01
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Exhibit A—Attachment 1 Al
ORGANIZATION AND ADMINISTRATION
2) A subcontractor of the Contractor, as governed by 42 C.F.R. §
438.230. (42 C.F.R. § 438.610(c)(2).)
3) A person with beneficial ownership of 5 percent or more of the
Contractor's equity. (42 C.F.R. § 438.610(c)(3).)
4) An individual convicted of crimes described in section 1128(b)(8)(B)
of the Act. (42 C.F.R. § 438.808(b)(2).)
5) A network provider or person with an employment, consulting, or
other arrangement with the Contractor for the provision of items
and services that are significant and material to the Contractor's
obligations under this Contract. (42 C.F.R. § 438.610(c)(4).)
6) The Contractor shall not employ or contract with, directly or
indirectly, such individuals or entities for the furnishing of health
care, utilization review, medical social work, administrative
services, management, or provision of medical services (or the
establishment of policies or provision of operational support for
such services). (42 C.F.R. § 438.808(b)(3).)
D. The Contractor shall provide to the Department written disclosure of any
prohibited affiliation identified by the Contractor or its subcontractors. (42
C.F.R. §438.608(c)(1).)
3. Delegation
Unless specifically prohibited by this contract or by federal or state law,
Contractor may delegate duties and obligations of Contractor under this contract
to subcontracting entities if Contractor determines that the subcontracting entities
selected are able to perform the delegated duties in an adequate manner in
compliance with the requirements of this contract. The Contractor shall maintain
ultimate responsibility for adhering to and otherwise fully complying with all terms
and conditions of its contract with the Department, notwithstanding any
relationship(s) that the Mental Health Plan may have with any subcontractor. (42
C.F.R. § 4&3438.230(b)(1).)
4. Subcontracts
A. This provision is a supplement to provision number five (Subcontract
Requirements) in Exhibit D(F) which is attached hereto as part of this
contract. As allowed by provision five in Exhibit D(F), the Department
County of Fresno
17-94581 A01
Page 3 of 6
Exhibit A—Attachment 1 Al
ORGANIZATION AND ADMINISTRATION
hereby, and until further notice, waives its right to prior approval of
subcontracts and approval of existing subcontracts.
B. No subcontract terminates the legal responsibility of the Contractor to the
Department to assure that all activities under this contract are carried out.
(42 C.F.R. § 438.230(b).)
C. All subcontracts shall be in writing.
D. All subcontracts for inpatient and residential services shall require that
subcontractors maintain necessary licensing and certification or mental
health program approval.
E. Each subcontract shall contain:
1) The delegated activities and obligations, including services
provided, and related reporting responsibilities. (42 C.F.R. §
438.230(c)(1)(i).)
2) The subcontractor's agreement to perform the delegated
activities and reporting responsibilities in compliance with the
Contractor's obligations in this Contract. (42 C.F.R. §
438.230(c)(1)(ii).)
3) Subcontractor's agreement to submit reports as required by the
Contractor and/or the Department.
4) The method and amount of compensation or other consideration to
be received by the subcontractor from the Contractor.
5) Requirement that the subcontract be governed by, and construed in
accordance with, all laws and regulations, and all contractual
obligations of the Contractor under this contract.
6) Requirement that the subcontractor comply with all applicable
Medicaid laws, regulations, including applicable sub-regulatory
guidance and contract provisions. (42 C.F.R. § 438.230(c)(2).)
7) Terms of the subcontract including the beginning and ending dates,
as well as methods for amendment and, if applicable, extension of
the subcontract.
County of Fresno
17-94581 A01
Page 4 of 6
Exhibit A—Attachment 1 Al
ORGANIZATION AND ADMINISTRATION
8) Provisions for full and partial revocation of the subcontract,
delegated activities or obligations, or application of other remedies
permitted by state or federal law when the Department or the
Contractor determine that the subcontractor has not performed
satisfactorily. (42 C.F.R. § 438.230(c)(1)(iii).)
9) The nondiscrimination and compliance provisions of this contract as
deSGribed onrExhih�ESeG}inn ti Paragraph C and SeG inn6
e e e
10) A requirement that the subcontractor make all of its premises,
physical facilities, equipment, books, records, documents,
contracts, computers, or other electronic systems pertaining to
Medi-Cal enrollees, Medi-Cal-related activities, services and
activities furnished under the terms of the subcontract, or
determinations of amounts payable available at any time for
inspection, examination or copying by the Department, CMS, HHS
Inspector General, the United States Comptroller General, their
designees, and other authorized federal and state agencies. (42
C.F.R. §438.230(c)(3)(i)-(ii)3(4).) This audit right will exist for 10
years from the final date of the contract period or from the date of
completion of any audit, whichever is later. (42 C.F.R. §
438.230(c)(3)(iii).) The Department, CMS, or the HHS Inspector
General may inspect, evaluate, and audit the subcontractor at any
time if there is a reasonable possibility of fraud or similar risk, then.
(42 C.F.R. § 438.230(c)(3)(iv).)
11) The Department's inspection shall occur at the subcontractor's
place of business, premises or physical facilities, in a form
maintained in accordance with the general standards applicable to
such book or record keeping, for a term of at least ten years from
the close of the state fiscal year in which the subcontract was in
effect. Subcontractor's agreement that assignment or delegation of
the subcontract shall be void unless prior written approval is
obtained from the Contractor.
12) A requirement that the Contractor monitor the subcontractor's
compliance with the provisions of the subcontract and this contract
and a requirement that the subcontractor provide a corrective
action plan if deficiencies are identified.
County of Fresno
17-94581 A01
Page 5 of 6
Exhibit A—Attachment 1 Al
ORGANIZATION AND ADMINISTRATION
13) Subcontractor's agreement to hold harmless both the State and
beneficiaries in the event the Contractor cannot or does not pay for
services performed by the subcontractor pursuant to the
subcontract.
14) Subcontractor's agreement to comply with the Contractor's policies
and procedures on advance directives and the Contractor's
obligations for Physician Incentive Plans, if applicable based on the
services provided under the subcontract.
5. Accreditation Status
A. The Contractor shall inform the Department whether it has been
accredited by a private independent accrediting entity. (42 C.F.R.
438.332(a).)
B. If the Contractor has received accreditation by a private independent
accrediting entity, the Contractor shall authorize the private independent
accrediting entity to provide the Department a copy of its most recent
accreditation review, including:
1) Its accreditation status, survey type, and level (as applicable);
2) Accreditation results, including recommended actions or
improvements, corrective action plans, and summaries of findings;
and
3) The expiration date of the accreditation. (42 C.F.R. § 438.332(b).)
6. Conflict of Interest
A. The Contractor shall comply with the conflict of interest safeguards
described in 42 Code of Federal Regulations part 438.58 and the
prohibitions described in section 1902(a)(4)(C) of the Social Security Act.
(42 C.F.R. § 438.3(f)(2).)
B. Contractor's officers and employees shall not have a financial interest in
this Contract or a subcontract of this Contract made by them in their
official capacity, or by any body or board of which they are members
unless the interest is remote. (Gov. Code §§ 1090, 1091; 42 C.F.R. §
438.3(f)(2).)
County of Fresno
17-94581 A01
Page 6 of 6
Exhibit A—Attachment 1 Al
ORGANIZATION AND ADMINISTRATION
C. No public officials at any level of local government shall make, participate
in making, or attempt to use their official positions to influence a decision
made within the scope of this Contract in which they know or have reason
to know that they have a financial interest. (Gov. Code §§ 87100, 87103;
Cal. Code Regs., tit. 2, § 18704; 42 C.F.R. §§ 438.3(f)(2).)
1) If a public official determines not to act on a matter due to a conflict
of interest within the scope of this Contract, the Contractor shall
notify the Department by oral or written disclosure. (Cal. Code
Regs., tit. 2, § 18707; 42 C.F.R. § 438.3(f)(2).)
2) Public officials, as defined in Government Code section 87200,
shall follow the applicable requirements for disclosure of a conflict
of interest or potential conflict of interest, once it is identified, and
recuse themselves from discussing or otherwise acting upon the
matter. (Gov. Code § 87105, Cal. Code Regs., tit. 2, § 18707(a); 42
C.F.R. § 438.3(f)(2).)
D. Contractor shall not utilize in the performance of this Contract any State
officer or employee in the State civil service or other appointed State
official unless the employment, activity, or enterprise is required as a
condition of the officer's or employee's regular State employment. (Pub.
Con. Code § 10410; 42 C.F.R. § 438.3(f)(2).)
1) Contractor shall submit documentation to the Department of
employees (current and former State employees) who may present
a conflict of interest.
County of Fresno
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Exhibit A—Attachment 2 Al
SCOPE OF SERVICES
1. Provision of Services
A. The Contractor shall provide or arrange, and pay for, the following
medically necessary covered specialty mental health services to
beneficiaries, as defined for the purposes of this contract, of Fresno
County. See Exhibit E, Attachment 2, Service Definitions, for detailed
descriptions of the specialty mental health services SM#S-listed
below:
1) Mental health services;
2) Medication support services;
3) Day treatment intensive;
4) Day rehabilitation;
5) Crisis intervention;
6) Crisis stabilization;
7) Adult residential treatment services;
8) Crisis residential treatment services;
9) Psychiatric health facility services;
10) Intensive Care Coordination (for beneficiaries under the age of 21);
11) Intensive Home Based Services (for beneficiaries under the age of
21);
12) Therapeutic Behavioral Services (for beneficiaries under the age of
21);
13) Therapeutic Foster Care (for beneficiaries under the age of 21);
14) Psychiatric Inpatient Hospital Services; and
County of Fresno
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Exhibit A—Attachment 2 Al
SCOPE OF SERVICES
15) Targeted Case Management; and
16) For beneficiaries under 21 years of age, the Contractor shall
provide all medically necessary specialty mental health
services required pursuant to Section 1396d(r) of Title 42 of
the United States Code (Welf. & Inst. Code 14184.402 (d)).
Coo Exhibit E 4ttaGhmont 2 Seryino Definitions for detailed deSGrin� s
vc� �-rrrn-c-���zu -r-rcrrr�Qcr-�rc�v i-rr i-r�--rvTa ca--crc�
of the QMHS listed above
B. Medi-Cal Managed Care Plan beneficiaries receive mental health
disorder benefits in every classification - inpatient, outpatient,
prescription drug and emergency - that the beneficiaries receive
medical/surgical benefits, in compliance with 42 C.F.R. 438.910(b)(2).
Contractor is only required to provide inpatient and outpatient
specialty mental health services, as provided for in this Contract, as
prescription drug and emergency benefits are provided through
other delivery systems.
C. Services shall be provided, in accordance with the State Plan, to
beneficiaries, who meet medical necessity criteria, based on the
beneficiary's need for services established by an assessment and
documented in the client plan. Services shall be provided in an amount,
duration, and scope as specified in the individualized Client Plan for each
beneficiary. Any Medi-Cal services not covered by the scope of this
contract will be provided through other Medi-Cal delivery systems.
D. The Contractor shall ensure that all medically necessary covered specialty
mental health services are sufficient in amount, duration, or scope to
reasonably achieve the purpose for which the services are furnished. The
Contractor shall not arbitrarily deny or reduce the amount, duration, or
scope of a medically necessary covered specialty mental health service
solely because of diagnosis, type of illness, or condition of the beneficiary
except as specifically provided in the medical necessity criteria applicable
to the situation as provided in the California Code of Regulations, title 9,
sections 1820.205, 1830.205, and 1830.210. (42 C.F.R. § 438.210(a)(2)
and (3).)
E. The Contractor shall make all medically necessary covered specialty
mental health services available in accordance with Cal.if,� Code of
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Exhibit A-Attachment 2 Al
SCOPE OF SERVICES
RegUlatieRs., tit.te 9, sections1810.345, 1810.350 and 1810.405, and 42
Code of Federal Regulations part 438.210.
F. The Contractor shall provide second opinions from a network provider, or
arrange for the beneficiary to obtain a second opinion outside the network,
at no cost to the beneficiary. (42 C.F.R § 438.206(b).) At the request of a
beneficiary when the Contractor or its network provider has determined
that the beneficiary is not entitled to specialty mental health services due
to not meeting the medical necessity criteria, the contractor shall provide
for a second opinion by a licensed mental health professional (other than
a psychiatric technician or a licensed vocational nurse). (Cal. Code Regs.,
tit. 9, § 1810.405(e).)
G. The Contractor shall provide a beneficiary's choice of the person providing
services to the extent feasible in accordance with Cal.if,� Code of
RegulatieRs., title. 9, section 1830.225 and 42 Code of Federal
Regulations part 438.3(I).
H. In d rminino whether a seFVi G-Ver rd i Rd outran based
��ef e,�-��ce-+s-c-��ea-tea c,mac
the diaonesis of the heneflola Fy the rontranter shall not evnli id a
e
henefiniary snlehi OR the ores Rd that the provider Fnakino the rliaonosis
has us- natienal Glassifination of diseases (IGD) diagnosis
systern than the system Gentained in the DiagnostiG and Statistinal
Manual (DSM) of the AmeriGan DsYnhiatrio Assoniation
2. Requirements for Day Treatment Intensive and Day Rehabilitation
A. The Contractor shall require providers to request payrneRt prior
authorization for day treatment intensive and day rehabilitation services, in
accordance with Information Notice 19-026 and any subsequent
departmental notices.
In adyanne of seryine delivery when day treatment intensive or day
rehabilitation will he provided for mere than five days per week.
2)At leaaJtevy three months fgrGC)ntiRuatien e�ytreaatmeRt
intensive
3)At least eveFy sox mORths feF GGRtiRuatien of day rehabilitation.
County of Fresno
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Exhibit A—Attachment 2 Al
SCOPE OF SERVICES
4) (; a' r shall also require providers to request a ti theriza�nnrfE)F
mental health seFVinese fi as dened in Galifornia Code of
RegUlatiORS, title 9,JeCtlr'n 'Ivrr-rv10.227,-roviaeGGRGUFF with
day treatment intensiyG or day rehabilitation, i i evnldinn seniines to
treat emernenGy and urgent nonditions as defined in California
(erode of RegulatiORS, title Q sentiens 1810.216 and 1810.253.
These s�FGS�all he authorized rued with the same freq i s the
Trrcvc� �cf cca-wT�rrcrrc sarrr�rrccicrzrrc
Gonnurrent day treatment intensive or day rehabilitation .., V nes
R The Centrao� shall notd� note the nayrnent a�i riZation fi�nntien to
n�nc-vvrnrac �riurrrry delegate crrcucr �rrccrorr
providers. When thcri-crrc-GORtrtaGtOF isthhe day treatmec-rRt lint i ie er day
Tulab+l+ta#1en provider, the CeRtra Gter shall
f assure that noymeeRt
+zetmen w f f��netion does not in ide staff in �e�r� nreyisien of
day trea#reR1 �'tte�e,day;eh tatieR.Eesr rne RtaT,hea���"
seryines nreyided Gonna irrent to day treatment intensive or day
rehabilitation se Wines
B. The Contractor shall require that providers of day treatment intensive and
day rehabilitation meet the requirements of Cal.ifGFRia Code of
RegUlatieRs., tit.te 9, SeGtiGRS §§ 1840.318, 1840.328, 1840.330,
1840.350 and 1840.352.
C. The Contractor shall require that providers include, at a minimum, the
following day treatment intensive and day rehabilitation service
components-
1) Community meetings. These meetings shall occur at least once a
day to address issues pertaining to the continuity and effectiveness
of the therapeutic milieu, and shall actively involve staff and
beneficiaries. Relevant discussion items include, but are not limited
to: the day's schedule, any current event, individual issues that
beneficiaries or staff wish to discuss to elicit support of the group
and conflict resolution. Community meetings shall:
a) For day treatment intensive, include a staff person whose
scope of practice includes psychotherapy.
b) For day rehabilitation, include a staff person who is a
physician, a licensed/waivered/registered psychologist,
County of Fresno
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Exhibit A—Attachment 2 Al
SCOPE OF SERVICES
clinical social worker, or marriage and family therapist; and a
registered nurse, psychiatric technician, licensed vocational
nurse, or mental health rehabilitation specialist.
2) Therapeutic milieu. This component must include process groups
and skill-building groups. Specific activities shall be performed by
identified staff and take place during the scheduled hours of
operation of the program. The goal of the therapeutic milieu is to
teach, model, and reinforce constructive interactions by involving
beneficiaries in the overall program. For example, beneficiaries are
provided with opportunities to lead community meetings and to
provide feedback to peers. The program includes behavior
management interventions that focus on teaching self-management
skills that children, youth, adults and older adults may use to control
their own lives, to deal effectively with present and future problems,
and to function well with minimal or no additional therapeutic
intervention. Activities include, but are not limited to, staff feedback
to beneficiaries on strategies for symptom reduction, increasing
adaptive behaviors, and reducing subjective distress.
3) Process groups. These groups, facilitated by staff, shall assist
each beneficiary to develop necessary skills to deal with his/her
problems and issues. The group process shall utilize peer
interaction and feedback in developing problem-solving strategies
to resolve behavioral and emotional problems. Day rehabilitation
may include psychotherapy instead of process groups, or in
addition to process groups.
4) Skill-building groups. In these groups, staff shall help beneficiaries
identify barriers related to their psychiatric and psychological
experiences. Through the course of group interaction, beneficiaries
identify skills that address symptoms and increase adaptive
behaviors.
5) Adjunctive therapies. These are therapies in which both staff and
beneficiaries participate. These therapies may utilize self-
expression, such as art, recreation, dance, or music as the
therapeutic intervention. Participants do not need to have any level
of skill in the area of self-expression, but rather be able utilize the
County of Fresno
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Exhibit A—Attachment 2 Al
SCOPE OF SERVICES
modality to develop or enhance skills directed toward achieving
beneficiary plan goals. Adjunctive therapies assist the beneficiary in
attaining or restoring skills which enhance community functioning
including problem solving, organization of thoughts and materials,
and verbalization of ideas and feelings. Adjunctive therapies
provided as a component of day rehabilitation or day treatment
intensive are used in conjunction with other mental health services
in order to improve the outcome of those services consistent with
the beneficiary's needs identified in the client plan.
D. Day treatment intensive shall additionally include:
1) Psychotherapy. Psychotherapy means the use of psychological
methods within a professional relationship to assist the beneficiary
or beneficiaries to achieve a better psychosocial adaptation, to
acquire a greater human realization of psychosocial potential and
adaptation, to modify internal and external conditions that affect
individual, groups, or communities in respect to behavior, emotions
and thinking, in respect to their intrapersonal and interpersonal
processes. Psychotherapy shall be provided by licensed,
registered, or waivered staff practicing within their scope of
practice. Psychotherapy does not include physiological
interventions, including medication intervention.
2) Mental Health Crisis Protocol. The Contractor shall ensure that
there is an established protocol for responding to beneficiaries
experiencing a mental health crisis. The protocol shall assure the
availability of appropriately trained and qualified staff and include
agreed upon procedures for addressing crisis situations. The
protocol may include referrals for crisis intervention, crisis
stabilization, or other specialty mental health services necessary to
address the beneficiary's urgent or emergency psychiatric condition
(crisis services). If the protocol includes referrals, the day
treatment intensive or day rehabilitation program staff shall have
the capacity to handle the crisis until the beneficiary is linked to an
outside crisis service.
3) Written Weekly Schedule. The Contractor shall ensure that a
weekly detailed schedule is available to beneficiaries and as
County of Fresno
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Exhibit A—Attachment 2 Al
SCOPE OF SERVICES
appropriate to their families, caregivers or significant support
persons and identifies when and where the service components of
the program will be provided and by whom. The written weekly
schedule will specify the program staff, their qualifications, and the
scope of their services.
E. Staffing Requirements. Staffing ratios shall be consistent with the
requirements in CaLifernia Code of-Regulations., tit.le 9, section 1840.350,
for day treatment intensive, and CaLif,� Code of-RegulatieRs., tit. 9
section 1840.352 for day rehabilitation. For day treatment intensive, staff
shall include at least one staff person whose scope of practice includes
psychotherapy.
a. Program staff may be required to spend time on day treatment
intensive and day rehabilitation activities outside the hours of operation
and therapeutic program (e.g., time for travel, documentation, and
caregiver contacts).
b. The Contractor shall require that at least one staff person be
present and available to the group in the therapeutic milieu for all
scheduled hours of operation.
C. The Contractor shall require day treatment intensive and day
rehabilitation programs to maintain documentation that enables Contractor
and the Department to audit the program if it uses day treatment intensive
or day rehabilitation staff who are also staff with other responsibilities
(e.g., as staff of a group home, a school, or another mental health
treatment program). The Contractor shall require that there is
documentation of the scope of responsibilities for these staff and the
specific times in which day treatment intensive or day rehabilitation
activities are being performed exclusive of other activities.
F. If a beneficiary is unavoidably absent and does not attend all of the
scheduled hours of the day rehabilitation or day treatment intensive
program, the Contractor shall ensure that the provider receives Medi-Cal
reimbursement only if the beneficiary is present for at least 50 percent of
scheduled hours of operation for that day. The Contractor shall require
that a separate entry be entered in the beneficiary record documenting the
reason for the unavoidable absence and the total time (number of hours
County of Fresno
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Exhibit A—Attachment 2 Al
SCOPE OF SERVICES
and minutes) the beneficiary actually attended the program that day. In
cases where absences are frequent, it is the responsibility of the
Contractor to ensure that the provider re-evaluates the beneficiary's need
for the day rehabilitation or day treatment intensive program and takes
appropriate action.
G. Documentation Standards. The Contractor shall ensure day treatment
intensive and day rehabilitation documentation meets the documentation
standards described in Attachment 9 of this exhibit. The documentation
shall include the date(s) of service, signature of the person providing the
service (or electronic equivalent), the person's type of professional
degree, Iicensure or job title, date of signature and the total number of
minutes/hours the beneficiary actually attended the program. For day
treatment intensive these standards include daily progress notes on
activities and a weekly clinical summary reviewed and signed by a
physician, a licensed/waivered/registered psychologist, clinical social
worker, or marriage and family therapist, or a registered nurse who is
either staff to the day treatment intensive program or the person directing
the services.
H. The Contractor shall ensure that day treatment intensive and day
rehabilitation have at least one contact per month with a family member,
caregiver or other significant support person identified by an adult
beneficiary, or one contact per month with the legally responsible adult for
a beneficiary who is a minor. This contact may be face-to-face, or by an
alternative method (e.g., e-mail, telephone, etc.). Adult beneficiaries may
decline this service component. The contacts should focus on the role of
the support person in supporting the beneficiary's community
reintegration. The Contractor shall ensure that this contact occurs outside
hours of operation and outside the therapeutic program for day treatment
intensive and day rehabilitation.
I. Written Program Description. The Contractor shall ensure there is a
written program description for day treatment intensive and day
rehabilitation. The written program description must describe the specific
activities of each service and reflects each of the required components of
the services as described in this section. The Contractor shall review the
written program description for compliance with this section with prior to
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Exhibit A—Attachment 2 Al
SCOPE OF SERVICES
the date the provider begins delivering day treatment intensive or day
rehabilitation.
J. Additional higher or more specific standards. The Contractor shall retain
the authority to set additional higher or more specific standards than those
set forth in this contract, provided the Contractor's standards are
consistent with applicable state and federal laws and regulations and do
not prevent the delivery of medically necessary day treatment intensive
and day rehabilitation.
K. Continuous Hours of Operation. The Contractor shall ensure that the
provider applies the following when claiming for day treatment intensive
and day rehabilitation services:
a. A half day shall be billed for each day in which the beneficiary
receives face-to-face services in a program with services available four
hours or less per day. Services must be available a minimum of three
hours each day the program is open.
b. A full-day shall be billed for each day in which the beneficiary
receives face-to-face services in a program with services available more
than four hours per day.
C. Although the beneficiary must receive face to face services on any
full-day or half-day claimed, all service activities during that day are not
required to be face-to-face with the beneficiary.
d. The requirement for continuous hours or operation does not
preclude short breaks (for example, a school recess period) between
activities. A lunch or dinner may also be appropriate depending on the
program's schedule. The Contractor shall not conduct these breaks
toward the total hours of operation of the day program for purposes of
determining minimum hours of service.
3. Therapeutic Behavioral Services
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Exhibit A—Attachment 2 Al
SCOPE OF SERVICES
Therapeutic Behavioral Services (TBS) are S,innlomon specialty mental health
services covered WRd the as Early and Periodic Screening, Diagnos+stic and
Treatment (EPSDT). benefit defined OR jCal.;f,� Code ef-RegefafiORS., tit. 9,
§_1810.215.) TBS are intensive, one-to-one services designed to help
beneficiaries and their parents/caregivers manage specific behaviors using short-
term measurable goals based on the beneficiary's needs. TBS are available to
benefiGiarnes in aGGerdanGe with is described in the Department of Mental
Health Information Notice 08-38. , the TBS Coordination o OG
r Manual,
Care Rost DraGt
Manual,�ersie;-2 (QGtebeF 2n1�- -0), and the TB D eG'S Urmi-rcentatien versi
2 (OGtober 2009)
County of Fresno
17-94581 A01
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Exhibit A—Attachment 3 Al
FINANCIAL REQUIREMENTS
1. Provider Compensation
The Contractor shall ensure that no payment is made to a network provider other
than payment the Contractor makes for services covered under this Contract,
except when these payments are specifically required to be made by the state in
Title XIX of the Act, in 42 Code of Federal Regulations in chapter IV, or when the
state agency makes direct payments to network providers for graduate medical
education costs approved under the State Plan. (42 C.F.R. § 438.60.)
2. Payments for Indian Health Care Providers
A. Contractor shall make payment to all Indian Health Care Providers
(IHCPs) in its network in a timely manner as required for payments to
practitioners in individual or group practices under 42 §§ C.F.R. 447.45-4
and 447.46 including paying 90% of all clean claims from practitioners
within 30 days of the date of receipt and paying 99 percent of all clean
claims from practitioners within 90 days of the date of receipt. (42 C.F.R.
438.14(b)(2).)
B. Contractor shall pay an IHCP that is not enrolled as a FQHC, regardless
of whether it is a network provider of the Contractor, its applicable
encounter rate published annually in the Federal Register by the Indian
Health Service or in the absence of a published encounter rate, the
amount the IHPC would receive if the services were provided under the
State plan's fee-for-service methodology. (42 C.F.R. § 438.14 (c)(2).)
3. Prohibited Payments
A. Federal Financial Participation is not available for any amount furnished to
an excluded individual or entity, or at the direction of a physician during
the period of exclusion when the person providing the service knew or had
reason to know of the exclusion, or to an individual or entity when the
Department failed to suspend payments during an investigation of a
credible allegation of fraud. (42 U.S.C. section 1396b(i)(2).)
B. In accordance with Section 1903(i) of the Social Security Act, the
Contractor is prohibited from paying for an item or service:
County of Fresno
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Exhibit A—Attachment 3 Al
FINANCIAL REQUIREMENTS
1) Furnished under this Contract by any individual or entity during any
period when the individual or entity is excluded from participation under
title V, XVIII, or XX or under this title pursuant to sections 1128, 1128A,
1156, or 18420)(2) of the Social Security Act.
2) Furnished at the medical direction or on the prescription of a physician,
during the period when such physician is excluded from participation
under title V, XVI 11, or XX or under this title pursuant to sections 1128,
1128A, 1156, or 18420)(2) of the Social Security Act and when the
person furnishing such item or service knew, or had reason to know, of
the exclusion (after a reasonable time period after reasonable notice
has been furnished to the person).
3) Furnished by an individual or entity to whom the state has failed to
suspend payments during any period when there is a pending
investigation of a credible allegation of fraud against the individual or
entity, unless the state determines there is good cause not to suspend
such payments.
4) With respect to any amount expended for which funds may not be
used under the Assisted Suicide Funding Restriction Act (ASFRA) of
1997.
4. Emergency Admission for Psychiatric Inpatient Hospital Services
The Contractor shall comply with Cal.Code Regs. Tit. 9 § 1820.225 regarding
emergency admission for psychiatric inpatient hospital services regarding
authorization and payment for both contract and non-contract hospitals.
5. Audit Requirements
The Contractor shall submit audited financial reports specific to this Contract on
an annual basis. The audit shall be conducted in accordance with generally
accepted accounting principles and generally accepted auditing standards. (42
C.F.R. § 438.3(m).)
6. Cost Reporting
A. The Contractor shall submit a fiscal year-end cost report no later than
December 31 following the close of each fiscal year, in accordance with
County of Fresno
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Exhibit A—Attachment 3 Al
FINANCIAL REQUIREMENTS
the Welf. & Inst. Code
� �§ 1470}�5(}c,)I, unless that date is extended by the
Department, n aGGerdanG.e�f+ti the Welf. S2. Inst. Code § 14705(G), and/or
guidelines established by the Department. Data submitted shall be full
and complete and the cost report shall be certified by the Contractor's
Mental Health Director and one of the following: (1) the Contractor's chief
financial officer (or equivalent), (2) an individual who has delegated
authority to sign for, and reports directly to, the Contractor's chief financial
officer, or (3) the Contractor's auditor-controller, or equivalent. The cost
report shall include both Contractor's costs and the cost of its
subcontractors, if any. The cost report shall be completed in accordance
with instructions contained in the Department's Cost and Financial
Reporting System Instruction Manual which can be accessed through the
Department's Information Technology Web Services (ITWS) for the
applicable year, as well as any instructions that are incorporated by
reference thereto; however, to the extent that the Contractor disagrees
with such instructions, it may raise that disagreement in writing with the
Department at the time the cost report is filed, and shall have the right to
appeal such disagreement pursuant to procedures developed under the
Welf. & Inst. Code § 14171.
B. In accordance with Welf. & Inst. Code § 5655, the Department shall
provide technical assistance and consultation to the Contractor regarding
the preparation and submission of timely cost reports. If the Contractor
does not submit the cost report by the reporting deadline, including any
extension period granted by the Department, the Department, in
accordance with Welf.& Inst. Code § 14197.7(o)(1)44742*( , may withhold
payments of additional funds until the cost report that is due has been
submitted.
C. Upon receipt of an amended cost report, which includes reconciled units
of service, and a certification statement that has been signed by the
Contractor's Mental Health Director and one of the following: 1) the
Contractor's Chief Financial Officer (or equivalent), (2) an individual who
has delegated authority to sign for, and reports directly to the Contractor's
Chief Financial Officer, or (3) the county's auditor controller, or equivalent,
the Department shall preliminarily settle the cost report. After completing
its preliminary settlement, the Department shall so notify the Contractor if
additional FFP is due to the Contractor. The Department shall submit a
claim to the federal government for the related FFP within 30 days
contingent upon sufficient budget authority. If funds are due to the State,
County of Fresno
17-94581 A01
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Exhibit A—Attachment 3 Al
FINANCIAL REQUIREMENTS
the Department shall invoice the Contractor and the Contractor shall
return the overpayment to the Department.
7. Recovery of Overpayments
A. The Contractor, and any subcontractor or any network provider of the
Contractor, shall report to the Department within 60 calendar days when it
has identified payments in excess of amounts specified for reimbursement
of Medicaid services. (42 C.F.R. § 438.608(c)(3).)
B. The Contractor, or subcontractor, to the extent that the subcontractor is
delegated responsibility for coverage of services and payment of claims
under this Contract, shall implement and maintain arrangements or
procedures that include provision for the suspension of payments to a
network provider for which the State, or Contractor, determines there is a
credible allegation of fraud. (42 C.F.R. §§ 438.608(a)(8) and 455.23.)
C. The Contractor shall specify the retention policies for the treatment of
recoveries of all overpayments from the Contractor to a provider, including
specifically the retention policies for the treatment of recoveries of
overpayments due to fraud, waste, or abuse. The policy shall specify the
process, timeframes, and documentation required for reporting the
recovery of all overpayments. The Contractor shall require its network
providers to return any overpayment to the Contractor within 60 calendar
days after the date on which the overpayment was identified. The
Contractor shall also specify the process, timeframes, and documentation
required for payment of recoveries of overpayments to the Department in
situations where the Contractor is not permitted to retain some or all of the
recoveries of overpayments. (42 C.F.R. § 438.608(d).)
8. Physician Incentive Plans
A. The Contractor shall obtain approval from the Department prior to
implementing a Physician Incentive Plan (Cal. Code Regs. tit. 9, §
1810.438(h).).
1) Pursuant to 42 Code of Federal Regulations part 438.3(i), the
Contractor shall comply with the requirements set forth in 42 C.F.R.
§§ 422.208 and 422.210.
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Exhibit A—Attachment 3 Al
FINANCIAL REQUIREMENTS
2) specific payment can be made directly or indirectly under a
Physician Incentive Plan to a physician or physician group as an
inducement to reduce or limit medically necessary services
furnished to a beneficiary. (42 C.F.R. § 422.208(c)(1).)
3) If a physician or physician group is put at substantial financial risk
for services not provided by the physician/group, the Contractor
shall ensure adequate stop-loss protection to individual physicians
and conduct annual beneficiary surveys. (42 C.F.R.
422.208 c 2 (#H
4) The Contractor shall provide information on its Physician Incentive
Plan to any Medicaid beneficiary upon request (this includes the
right to adequate and timely information on a Physician Incentive
Plan). Such information shall include: whether the Contractor uses
a physician incentive plan that affects the use of referral services,
(2) the type of incentive arrangement, and (3) whether stop-loss
protection is provided. (42 C.F.R. § 422.210(b).)
9. Financial requirements
A. The Contractor shall not impose financial requirements or
cumulative financial requirements, as defined in 42 C.F.R. 438.900,
for any beneficiary receiving specialty mental health services.
.RQenefic; ary Liability for Payment
B. The wiTm'aEtOF Or an affiliate,vr ncR OF, GGRtraacter,�ubGenr, craaEtOr of the
GORtrantor shall not submit a nlaim to or demand or otherwise nnllent
e
reimbursement from the heneflnlary or persons aGtino on behalf of the
r
henefiniary for any specialty mental health or related administrati .
sepiines provided under this sentrast evnept to GGIIest other health
i ar Ge GO ieraoe share of nest and no payments (Gal Gede Revs
tit Q § 1810.365 (a)-.)
G. he (�aaGtO^ or an affiliate vendGF, GentraaGtor,or sub__ssYbGenta r of
the Gentrantnr shall not hold henefiGiaries liable for debts in the event that
the Gentrantor henomes insolvent• for nests of soyererd se Wines for��ihinh
0
County of Fresno
17-94581 A01
Page 6 of 7
Exhibit A-Attachment 3 Al
FINANCIAL REQUIREMENTS
the State goes not pay the ntraG� re�for Gests o of se�fGesie
�
which the State or the Gentragtor does not nazi the Centronter's network
providers; for nests of hovered serVines provided under a Gentrant referral
e
or other arrangement rather than from the GentraGter• or for payment of
e
subsequent sGreenand treatment needed to dia ethe S;eg
GendifiG
+ti��tabilize a-benefioraf�42 C.F:P�438. nd Cal Code
C?egs tit Q C 1 Q1 n 36 5(G)
D. r�vvrnrtraEter shall tYeRSUre-its subGOR-traGte-rs and providers do bill
benchDiaries for Tiered-se�Gs y amni int greater than mini ild he
crt�rrc��rvr,�v�r ,
never d if the Gentra r preyideit�SeNiGes ircetly (42 G.F.R. f:
4 83.1 0 (G 1
1111. Cost Sharing
A. The (;entrantnr shall
^ensi iire that any nest sharing impesed op
benefigia� i's if}aEGGpdanGe with 42 Code of Feder-al part
447.50 threugh 447 82 (42 (�§438..1�)
B. The (�nntroe�� exempt l� sharing any Indian who is
D�flL�1TCrQ "���N
G irrentl�,i}r.,enei�ii q eer has ever i i reneiyed an item or seryige frnished by an
lHCPo #rou h referral. (42 G.F.R. § 447.56(a)(1)(x)
10. ICD- 10
A. The Contractor shall use the criteria sets in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) as the clinical tool to
make diagnostic determinations.
B. Once a DSM-5 diagnosis is determined, the Contractor shall determine
the corresponding mental health diagnosis, in the International
Classification of Diseases and Related Health Problems, Tenth Revision
(ICD-10).
C. The Contractor shall use the ICD-10 diagnosis code(s) to submit a claim
for specialty mental health services to receive reimbursement of Federal
Financial Participation (FFP) in accordance with the covered diagnoses for
reimbursement of outpatient and inpatient Medi-Cal specialty mental
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Exhibit A—Attachment 3 Al
FINANCIAL REQUIREMENTS
health services listed in Mental Health and S bstanno Use Disorder
SerViGes Behavioral Health Information Notice (BHIN) 47—
004€20-043.
D. The lists of covered ICD-10 diagnosis codes in MHSUDS Information
e-BHIN 1'�F=20-043 are subject to change and the Department
may update them during the term of this contract. Changes to the lists of
covered ICD-10 covered diagnoses do not require an amendment to this
contract and the Department may implement these changes via Mental
Health and SubstaRGe Use DiserderSeFViGeS Information Notices.
County of Fresno
17-94581 A01
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Exhibit A—Attachment 4 Al
MANAGEMENT INFORMATION SYSTEMS
1. Health Information Systems
A. The Contractor shall maintain a health information system that collects,
analyzes, integrates, and reports data. (42 C.F.R. § 438.242(a); Cal. Code
Regs., tit. 9, § 1810.376.) The system shall provide information on areas
including, but not limited to, utilization, claims, grievances, and appeals.
(42 C.F.R. § 438.242(a).) The Contractor shall comply with Section
6504(a) of the Affordable Care Act which requires that State claims
processing and retrieval systems are able to collect data elements
necessary to enable the mechanized claims processing and information
retrieval systems in operation by the State to meet the requirements of
section 1903(r)(1)(F) of the Social Security Act. (42 C.F.R. §
438.242(b)(1).)
B. The Contractor's health information system shall, at a minimum:
1) Collect data on beneficiary and provider characteristics as specified
by the Department, and on services furnished to beneficiaries as
specified by the Department; (42 C.F.R. § 438.242(b)(2).)
2) Ensure that data received from providers is accurate and complete
by:
a. Verifying the accuracy and timeliness of reported data,
including data from network providers compensated on the
basis of capitation payments; (42 C.F.R. § 438.242(b)(3)(i).)
b. Screening the data for completeness, logic, and consistency;
and (42 C.F.R. § 438.242(b)(3)(ii).)
C. Collecting service information in standardized formats to the
extent feasible and appropriate, including secure information
exchanges and technologies utilized for quality improvement
and care coordination efforts. (42 C.F.R. § 438.242(b)(3)(iii).)
3) Make all collected data available to the Department and, upon
request, to CMS. (42 C.F.R. § 438.242(b)(4).)
County of Fresno
17-94581 A01
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Exhibit A—Attachment 4 Al
MANAGEMENT INFORMATION SYSTEMS
C. The Contractor's health information system is not required to collect and
analyze all elements in electronic formats. (Cal. Code Regs., tit. 9, §
1810.376(c).)
2. Encounter Data
The Contractor shall submit encounter data to the Department at a frequency
and level specified by the Department and CMS. (42 C.F.R. § 438.242(c)(2).)
The Contractor shall ensure collection and maintenance of sufficient beneficiary
encounter data to identify the provider who delivers service(s) to the beneficiary.
(42 C.F.R. § 438.242(c)(1).) The Contractor shall submit all beneficiary encounter
data that the Department is required to report to CMS under § 438.818. (42
C.F.R. § 438.242(c)(3).) The Contractor shall submit encounter data to the state
in standardized Accredited Standards Committee (ASC) X12N 837 and National
Council for Prescription Drug Programs (NCPDP) formats, and the ASC X12N
835 format as appropriate. (42 C.F.R. § 438.242(c)(4).)
3.Med%lEligibility Ila}�rt (MEDS) and IVIEDS Monthly t File
(M System
`�'
The GeRtraGtGF shall eRter iRte a Tedi_Cal Prl\/aGy and SeGWri+�Teeme t
(PSA) with the DepaFtMen+ prier to E)btaif aF.�S tG MEDS and the MEDS
MORthly extraGt file }�o (`�a� Gr`agrees+#�n�'GOMply with +ho
prepiiSiens as spe"cifieed-OR the PC�,h,e (.'c-GeUR+ry agrees
ueaal-thr-D-ireEter or�Gr
with th-r�e, DC�reemen+. Failure W GOmr��+h�ter�tthe agreeemre Rt
result OR the-tercrmmatiOR of aGGess to nnEnS and nnnnEC (4 112_r�_S.G §
§ 14 1 nn 2re4 +
County of Fresno
17-94581 A01
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Exhibit A—Attachment 5 Al
QUALITY IMPROVEMENT SYSTEM
1. Quality Assessment and Performance Improvement
A. The Contractor shall implement an ongoing comprehensive Quality
Assessment and Performance Improvement (QAPI) Program for the
services it furnishes to beneficiaries. (42 C.F.R. § 438.330 (a).)
B. The Contractor's QAPI Program shall improve Contractor's established
outcomes through structural and operational processes and activities that
are consistent with current standards of practice.
C. The Contractor shall have a written description of the QAPI Program that
clearly defines the QAPI Program's structure and elements, assigns
responsibility to appropriate individuals, and adopts or establishes
quantitative measures to assess performance and to identify and prioritize
area(s) for improvement. Contractor shall evaluate the impact and
effectiveness of its QAPI Program annually and update the Program as
necessary per Cal. Code Regs., tit. 9, § 1810.440(a)(6). (42 C.F.R. §
438.330(e)(2).)
D. The QAPI Program shall include collection and submission of performance
measurement data required by the Department, which may include
performance measures specified by CMS. The Contractor shall measure
and annually report to the Department its performance, using the standard
measures identified by the Department. (42 C.F.R. § 438.330 (a)(2),
(b)(2), (c)(2).)
E. The Contractor shall conduct performance monitoring activities throughout
the Contractor's operations. These activities shall include, but not be
limited to, beneficiary and system outcomes, utilization management,
utilization review, provider appeals, credentialing and monitoring, and
resolution of beneficiary grievances.
F. The Contractor shall have mechanisms to detect both underutilization of
services and overutilization of services. (42 C.F.R. § 438.330(b)(3).)
G. The Contractor shall implement mechanisms to assess beneficiary/family
satisfaction. The Contractor shall assess beneficiary/family satisfaction
by:
County of Fresno
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Exhibit A—Attachment 5 Al
QUALITY IMPROVEMENT SYSTEM
1) Surveying beneficiary/family satisfaction with the Contractor's
services at least annually;
2) Evaluating beneficiary grievances, appeals and fair hearings at
least annually; and
3) Evaluating requests to change persons providing services at least
annually.
4) The Contractor shall inform providers of the results of
beneficiary/family satisfaction activities.
H. The Contractor shall implement mechanisms to monitor the safety and
effectiveness of medication practices. The monitoring mechanism shall be
under the supervision of a person licensed to prescribe or dispense
prescription drugs. Monitoring shall occur at least annually.
I. The Contractor shall implement mechanisms to address meaningful
clinical issues affecting beneficiaries system-wide.
J. The Contractor shall implement mechanisms to monitor appropriate and
timely intervention of occurrences that raise quality of care concerns. The
Contractor shall take appropriate follow-up action when such an
occurrence is identified. The results of the intervention shall be evaluated
by the Contractor at least annually.
K. Contractor's QAPI Program shall include Performance Improvement
Projects as specified in paragraph 5.
2. Quality Improvement (QI) Work Plan
A. The Contractor shall have a Quality Improvement (QI) Work Plan covering
the current contract cycle with documented annual evaluations and
documented revisions as needed. The QI Work Plan shall include:
1) Evidence of the monitoring activities including, but not limited to,
review of beneficiary grievances, appeals, expedited appeals, fair
hearings, expedited fair hearings, provider appeals, and clinical
records review as required by Cal. Code Regs., tit. 9, §
1810.440(a)(5) and 42 C.F.R. § 438.416(a);
County of Fresno
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Exhibit A—Attachment 5 Al
QUALITY IMPROVEMENT SYSTEM
2) Evidence that QI activities, including performance improvement
projects, have contributed to meaningful improvement in clinical
care and beneficiary service;
3) A description of completed and in-process QI activities, including
performance improvement projects. The description shall include:
a. Monitoring efforts for previously identified issues, including
tracking issues over time;
b. Objectives, scope, and planned QI activities for each year;
and,
C. Targeted areas of improvement or change in service delivery
or program design.
4) A description of mechanisms the Contractor has implemented to
assess the accessibility of services within its service delivery area.
This shall include goals for responsiveness for the Contractor's 24-
hour toll-free telephone number, timeliness for scheduling of routine
appointments, timeliness of services for urgent conditions, and
access to after-hours care; and
5) Evidence of compliance with the requirements for cultural
competence and linguistic competence specified in Attachments 7
and 11.
3. Quality Improvement (QI) Committee and Program
A. The Contractor's QI program shall monitor the Contractor's service
delivery system with the aim of improving the processes of providing care
and better meeting the needs of its beneficiaries.
B. The Contractor shall establish a QI Committee to review the quality of
specialty mental health services provided to beneficiaries. The QI
Committee shall recommend policy decisions; review and evaluate the
results of QI activities, including performance improvement projects;
institute needed QI actions; ensure follow-up of QI processes; and
County of Fresno
17-94581 A01
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Exhibit A—Attachment 5 Al
QUALITY IMPROVEMENT SYSTEM
document QI Committee meeting minutes regarding decisions and actions
taken.
C. The QI Program shall be accountable to the Contractor's Director as
described in Cal. Code Regs., tit. 9, § 1810.440(a)(1).
D. Operation of the QI program shall include substantial involvement by a
licensed mental health professional. (Cal. Code. Regs., tit. 9, §
1810.440(a)(4).)
E. The QI Program shall include active involvement partinipatief in the
planning, design and execution of the QI Program by the Contractor's
practitioners and providers, as well as beneficiaries who have accessed
specialty mental health services through the Contractor, apA family
members, legal representatives, or other persons similarly involved
with beneficiariesin the plaRRORg rdesigR and exeGUtiGR of the 4al
Drnn vgraRrras described in Cal. Code. Regs., tit. 9, § 1810.440(a)(2)(A-C).
F. QI activities shall include:
1) Collecting and analyzing data to measure against the goals, or
prioritized areas of improvement that have been identified;
2) Identifying opportunities for improvement and deciding which
opportunities to pursue;
3) Identifying relevant committees internal or external to the
Contractor to ensure appropriate exchange of information with the
QI Committee;
4) Obtaining input from providers, beneficiaries and family members in
identifying barriers to delivery of clinical care and administrative
services;
5) Designing and implementing interventions for improving
performance;
6) Measuring effectiveness of the interventions;
County of Fresno
17-94581 A01
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Exhibit A—Attachment 5 Al
QUALITY IMPROVEMENT SYSTEM
7) Incorporating successful interventions into the Contractor's
operations as appropriate; and
8) Reviewing beneficiary grievances, appeals, expedited appeals, fair
hearings, expedited fair hearings, provider appeals, and clinical
records review as required by Cal. Code Regs., tit. 9, §
1810.440(a)(5).
4. External Quality Review
The Contractor shall undergo annual, external independent reviews of the
quality, timeliness, and access to the services covered under this Contract, which
are conducted pursuant to Subpart E of Part 438 of the Code of Federal
Regulations. (42 C.F.R. §§ 438.350(a) and 438.320)
5. Performance Improvement Projects
A. The Contractor shall conduct a minimum of two Performance
Improvement Projects (PIPs) per year, including any PIPs required by
DHCS or CMS. DHCS may require additional PIPs. One PIP shall focus
on a clinical area and one on a non-clinical area. (42 C.F.R. §
438.330(b)(1) and (d)(1).) Each PIP shall:
1) Be designed to achieve significant improvement, sustained over
time, in health outcomes and beneficiary satisfaction;
2) Include measurement of performance using objective quality
indicators;
3) Include implementation of interventions to achieve improvement in
the access to and quality of care;
4) Include an evaluation of the effectiveness of the interventions
based on the performance measures collected as part of the PIP;
and,
5) Include planning and initiation of activities for increasing or
sustaining improvement. (42 C.F.R. § 438.330(d)(2).)
County of Fresno
17-94581 A01
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Exhibit A—Attachment 5 Al
QUALITY IMPROVEMENT SYSTEM
B. The Contractor shall report the status and results of each performance
improvement project to the Department as requested, but not less than
once per year. (42 C.F.R. § 438.330(d)(3).)
6. Practice Guidelines
A. The Contractor shall adopt practice guidelines. (42 C.F.R. § 438.236(b)
and Cal. Code Regs., tit. 9, § 1810.326)
B. Such guidelines shall meet the following requirements:
1) They are based on valid and reliable clinical evidence or a
consensus of health care professionals in the applicable field;
2) They consider the needs of the beneficiaries;
3) They are adopted in consultation with network providers
GontraCtiRg health nape Prnf000innals; and
4) They are reviewed and updated periodically as appropriate. (42
C.F.R. § 438.236(b).)
C. Contractor shall disseminate the guidelines to all affected providers and,
upon request, to beneficiaries and potential beneficiaries. (42 C.F.R. §
438.236(c).)
D. Contractor shall take steps to assure that decisions for utilization
management, beneficiary education, coverage of services, and any other
areas to which the guidelines apply shall be consistent with the guidelines.
(42 C.F.R. § 438.236(d)
County of Fresno
17-94581 A01
Page 1 of 4
Exhibit A—Attachment 6 Al
UTILIZATION MANAGEMENT PROGRAM
1. Utilization Management
A. The Contractor shall operate a Utilization Management Program that is
responsible for assuring that beneficiaries have appropriate access to
specialty mental health services as required in Cal.ifernia Code of
Regulations., title 9, section 1810.440(b)(1)-(3).
B. The Utilization Management Program shall evaluate medical necessity,
appropriateness and efficiency of services provided to Medi-Cal
beneficiaries prospectively or retrospectively.
C. Compensation to individuals or entities that conduct utilization
management activities must not be structured so as to provide incentives
for the individual or entity to deny, limit, or discontinue medically
necessary services to any beneficiary. (42 C.F.R. § 438.210(e).)
D. The Contractor may place appropriate limits on a service based on criteria
applied under the State Plan, such as medical necessity and for the
purpose of utilization control, provided that the services furnished are
sufficient in amount, duration or scope to reasonably achieve the purpose
for which the services are furnished. (42 C.F.R. § 438.210(a)(4)(i), (ii)(A).)
E. The Contractor shall not impose quantitative treatment limitations,
aggregate lifetime or annual dollar limits as defined in 42 C.F.R.
438.900, for any beneficiary receiving specialty mental health
services.
F. The Contractor shall not impose non-quantitative treatment
limitations for specialty mental health services in any benefit
classification (i.e., inpatient and outpatient) unless the Contractor's
policies and procedures have been determined by the Department to
comply with Title 42 of the Code of Federal Regulations, subpart K.
(42 C.F.R. § 438.910(d).)
G. The Contractor shall submit to the Department, upon request, any
policies and procedures or other documentation necessary for the
State to establish and demonstrate compliance with Title 42 of the
Code of Federal Regulations, part 438, subpart K, regarding parity in
mental health and substance use disorder benefits.
County of Fresno
17-94581 A01
Page 2 of 4
Exhibit A—Attachment 6 Al
UTILIZATION MANAGEMENT PROGRAM
2. Service Authorization
A. Contractor shall implement mechanisms to assure authorization decision
standards are met in accordance with Mental Health and Substance
Use Disorder Services (MHSUDS) Information Notice 19-026, or any
subsequent Departmental notices issued to address parity in mental
health and substance use disorder benefits subsequent to the
effective date of this contract, and any applicable state and federal
regulations. (42 C.F.R. § 438.910(d).) The Contractor shall:
1) Have in place, and follow, written policies and procedures for
processing requests for initial and continuing authorizations of
services. (42 C.F.R. § 438.210(b)(1).)
2) Have mechanisms in effect to ensure consistent application of
review criteria for authorization decisions, and shall consult with the
requesting provider when appropriate. (42 C.F.R. § 438.210(b)(2)(i-
ii).)
3) Have any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less
than requested be made by a health care professional who has
appropriate clinical expertise in addressing the beneficiary's
behavioral health needs. (42 C.F.R. § 438.210(b)(3).)
4) Notify the requesting provider and give the beneficiary written
notice of any decision by the Contractor to deny a service
authorization request, or to authorize a service in an amount,
duration, or scope that is less than requested. (42 C.F.R. §
438.210(c)) The beneficiary's notice shall meet the requirements in
Attachment 12, Section 10, paragraph A and Section 9, paragraph I
and be provided within the timeframes set forth in Attachment 12,
Section 10, paragraph B and Section 9, paragraph-l-G.
DR For standard authorization deni�siionn? the Gentra r shall nreyide notin`�e
as expeditiously as the henefiGiaFY's nondition requires not to exneed 14
Galendar days fell eCpjpt of the fo�� no with a possible
extension of up to 14 additional nalendar days when:
County of Fresno
17-94581 A01
Page 3 of 4
Exhibit A-Attachment 6 Al
UTILIZATION MANAGEMENT PROGRAM
1 The benefiGiary, or the provider, requests exTensi��or
2) The GentraGtG ii�s s (to the Department upon request) need
�T�c-wiTrrcrc �Cr`r �\c� cparcrrTcrn-apvr-�Tcc�uc� ccr
for additional information and how the extension is in the
beneficiary's interest.-(42 r�§438.21 n�})
B. The Contractor shall comply with authorization timeframes in
accordance with MHSUDS Information Notice 19-026, or any
subsequent Departmental notices issued to address parity in mental
health and substance use disorder benefits subsequent to the
effective date of this contract, as well as any applicable state and
federal regulations. (42 C.F.R. § 438.910(d).)
C. For cases in which a provider indicates, or the Contractor determines, that
following the standard timeframe could seriously jeopardize the
beneficiary's life or health or ability to attain, maintain, or regain maximum
function, the Contractor shall make an expedited authorization decision
and provide notice as expeditiously as the beneficiary's health condition
requires and no later than 72 hours after receipt of the request for service.
The Contractor may extend the 72-hour time period by up to 14 calendar
days if the beneficiary requests an extension, or if the Contractor justifies
(to the Department upon request) a need for additional information and
how the extension is in the beneficiary's interest. (42 C.F.R. §
438.210(d)(2))
D. The Contractor shall act on an authorization request for treatment for
urgent conditions within one hour of the request. (Cal. Code Regs., tit. 9,
§§ 1810.253 1810.405, subd. (c)).
E. The Contractor shall not require prior authorization for an emergency
admission for psychiatric inpatient hospital services, whether the
admission is voluntary or involuntary. (Cal. Code Regs., tit. 9, §§
1820.200(d) and 1820.225). The Contractor that is the MHP of the
beneficiary being admitted on an emergency basis shall approve a request
for payment authorization if the beneficiary meets the criteria for medical
necessity and the beneficiary, due to a mental disorder, is a current
danger to self or others, or immediately unable to provide for, or utilize,
County of Fresno
17-94581 A01
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Exhibit A—Attachment 6 Al
UTILIZATION MANAGEMENT PROGRAM
food, shelter or clothing. (Cal Code Regs, tit. 9 §§ 1820.205 and
1820.225).
.The ('�aGtor may Rot require prior of i riztiOn for an emergennY
admission to a psyGhiatrin health fanility when the henefioiary has an
emr � l triG GondT (Cal.- Code tegs•, t,i-tem Q §§ 9�0.2�1 6
and1830 ` 45)
E. A CGRtran�- shall ai i rite of t Of petworh seFViGes when a hen�Giary
crac �riurrucr cc�cr r-rrcc-vvvrrr�crvr�Tcrrcrvcrr `"'``""��77
with an emergency psYnhiatrin rendition is admitted en an emernenny
basis for PSYGhiatFiG inpatient hospital seFViGGS OF PSYGhiatFiG health faGility
vef F e�S•, +i+ a §§ 1830.220, 1810.216, gZn�, and
11 83
The Contractor shall define service authorization request in a manner that
at least includes a beneficiary's request for the provision of a service. (42
C.F.R. § 431.201)
County of Fresno
17-94581 A01
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Exhibit A—Attachment 7 Al
ACCESS AND AVAILABILITY OF SERVICES
1. Beneficiary Enrollment
A. Medi-Cal eligible beneficiaries are automatically enrolled in the single
MHP in their county. (1915(b) waiver, § A, part I, para. CA, p. 31.)
B. The Contractor shall be responsible for providing or arranging and paying
for specialty mental health services for Medi-Cal eligible individuals in its
county who require an assessment or meet medical necessity criteria for
specialty mental health services. (Cal. Code Regs. tit. 9, §1810.228.) The
Contractor shall accept these individuals in the order in which they are
referred (including self-referral) without restriction (unless authorized by
CMS), up to the limits set under this Contract. (42 C.F.R. § 438.3(d)(1).)
C. The Contractor shall not, on the basis of health status or need for health
care services, discriminate against Medi-Cal eligible individuals in its
county who require an assessment or meet medical necessity criteria for
specialty mental health services. (42 C.F.R. § 438.3(d)(3).)
D. The Contractor shall not unlawfully discriminate against Medi-Cal eligible
individuals in its county who require an assessment or meet medical
necessity criteria for specialty mental health services on the basis of race,
color, national origin, sex, sexual orientation, gender, gender identity,
religion, marital status, ethnic group identification, ancestry, age,
medical condition, genetic information, mental disability, or physical
disability, and will not use any policy or practice that has the effect of
discriminating on the basis of race, color, of national origin, sex, sexual
orientation, gender, gender identity, religion, marital status, ethnic
group identification, ancestry, age, medical condition, genetic
information, mental disability, or physical disability. (42 U.S.C. §
18116; 42 C.F.R. § 438.3(d)(4); 45 C.F.R. § 92.2; Gov. Code § 11135(a);
Welf. & Inst. Code § 14727(a)(3).)
2. Cultural Competence
A. The Contractor shall participate in the State's efforts to promote the
delivery of services in a culturally competent manner to all beneficiaries,
including those with limited English proficiency and diverse cultural and
ethnic backgrounds, disabilities, and regardless of gender, sexual
orientation or gender identity. (42 C.F.R. § 438.206(c)(2).)
County of Fresno
17-94581 A01
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Exhibit A—Attachment 7 Al
ACCESS AND AVAILABILITY OF SERVICES
B. The Contractor shall comply with the provisions of the Contractor's
Cultural Competence Plan submitted and approved by the Department.
The Contractor shall update the Cultural Competence Plan and submit
these updates to the Department for review and approval annually. (Cal.
Code Regs., tit. 9, § 1810.410, subds. (c)-(d).)
3. Out-of-Network Services
A. If the Contractor's provider network is unable to provide necessary
services, covered under this Contract, to a particular beneficiary, the
Contractor shall adequately and timely cover the services out of network,
for as long as the Contractor's provider network is unable to provide them.
(42 C.F.R. § 438.206(b)(4).)
B. The Contractor shall require that out-of-network providers coordinate
authorization and payment with the Contractor. The Contractor must
ensure that the cost to the beneficiary for services provided out of network
pursuant to an authorization is no greater than it would be if the services
were furnished within the Contractor's network, consistent with Cal. a
Code of-RegulatisRs., tit.te 9, section 1810.365. (42 C.F.R. §
438.206(b)(5).)
C. Contractor shall comply with the requirements of Calera. Code of
Regela#+eos, tit.le 9, section 1830.220 regarding providing beneficiaries
access to out-of-network providers when a provider is available in
Contractor's network.
D. Pursuant to Department guidance, Contractor shall submit to the
Department for approval policies and procedures regarding
authorization of out-of-network services to establish compliance with
title 42 of the Code of Federal Regulations, section 438.910(d)(3).
4. Procedures for Serving Child Beneficiaries Foster Children Placed Out-of-
County
A. In accordance with Cal. Code Regs,tot o § 1830 228Welf. & Inst. Code
14717.1, the Contractor in the foster nhild's nnunh, of origin resid non
shall be responsible to authorize, pay, provide or arrange for medically
County of Fresno
17-94581 A01
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Exhibit A—Attachment 7 Al
ACCESS AND AVAILABILITY OF SERVICES
necessary specialty mental health services forte foster children in-a
foster Gare and Geale residing in the Contractor's county, who are
placed outside of their counties of origin, unless a presumptive transfer
waiver is in place. The Contractor shall follow the Mental Health and
Substance Use Disorder Services Information Notices pertaining to
Presumptive Transfer for Foster Children Placed Out of County
(MHSUDS IN 17-032, 18-027, BHIN 19-041, and any subsequent
Information Notices). These Information Notices include
standardized templates that the Contractor may use or adapt to the
Contractor's needs.
B. The Contractor shall accept a completed mental health assessment
from the foster child's county of origin mental health plan. The
Contractor may conduct additional assessments if the foster child's
needs change or an updated assessment is needed to determine the
child's needs and identify the needed treatment and services to
address those needs.
C. When a request for a presumptive transfer waiver has been made for
a foster child from the Contractor county who is being placed
outside of the Contractor's county, the Contractor shall continue to
provide medically necessary specialty mental health services to that
foster child until a presumptive transfer waiver determination has
been made.
D. The Contractor shall be responsible to authorize, pay, provide or
arrange for medically necessary specialty mental health services for
foster children originally from the Contractor's county who are
residing outside of the Contractor's county, if a presumptive transfer
waiver is in place.
E. The GentraGtor shall provide sneniolt i mental health serVines and annent
an assessment, Of one exosts—, ef needed speGoalty rne-ntal health
fer the fostTGhild from the MHP in the not int of original ii irisrtT/+t�.
Nothonq should PF&Glude the nntraGtor from i pdatin the assessment of
GendUGtinq a new assessment of nlinoGall i inrdinated but these updates or
new assessments shall not delay the timely provision of speGially mental
health seFVwGes to the foster nhilr!
County of Fresno
17-94581 A01
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Exhibit A-Attachment 7 Al
ACCESS AND AVAILABILITY OF SERVICES
F. The (;E)RtFaGtE)F shall use the StandaFd fGFMG 0666led by the [DepaFtMeRt, OF
ppaeed o,,tside of hiS/heG0,,nty of erigin The standard fermS are:
) GlieRt Assessment,
2rlieRt Plan,
3)S r"iGer a Authorization Terv�t
/1��eRt Assessr,nTenMace } I
5) Drogr ss NvtC��TeatrmrRt Rtensi�. vcrvTf"ne
6) Progress Notes [Day Rehabilitation SeryiC$s,
77) Qr�T atienel DreyirJer Agre8M char (`entrec})
G. (�a r may request eXerr,ption from ,,Sing the standard
don, Ments if the ('ontranter iS s,ihient to an evternally planer! rent,iremept
,
S,,nh as a federal ipt8grity ar,reerr,ent, that pre"ents the use of the
standardized forme The (`entry r Shall request this emptiop from
v�urraa-a,Zca-rvrn,��,c-vvrrcra rn-rrcq-ac�rre�C the
department in WFitin_
5. Children in Adoption Assistance Program (AAP) and Kinship Guardian
Assistance Payment (Kin-GAP)
A. The Contractor shall eRsure that the nnu�rthe Ghildcrye pareRtS'
r+e,,nty of residence provides or arrange for the provision of medically
necessary specialty mental health services to a child in a-Rthe Adoption
Assistance Program (AAP) aide residing within their adoptive
parents' county of residence in the Contractor's county. These
services are to be provided eutside his er her no,,nfi, of erigin in the
same way as the M#PContractor would provide services to an oy ther iR-
r'OURty child for whom the M#PContractor county is listed as the county
of responsibility on the Medi-Cal Eligibility Data System (MEDS). When
treatment authorization requests are required, the Contractor shall
be responsible for submitting treatment authorization requests to the
mental health plan in the child's county of origin. (Welf. & Inst. Code
16125.
B. The MHP in the Child's legal guardians' no,into of residenneThe
Contractor shall provide or arrange for the provision of medically
County of Fresno
17-94581 A01
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Exhibit A—Attachment 7 Al
ACCESS AND AVAILABILITY OF SERVICES
necessary specialty mental health services to a child in the a-Kinship-
Guardian Assistance Program (Kin-GAP) and ^tee residing within their
legal guardian's county of residence in the Contractor's county.
These services are to be provided outside his or her GGunt„ of origin in
the same way that +tthe Contractor would provide services to any other
child for whom the MHPContractor county is listed as the county of
responsibility iron the MEDS. When treatment authorization requests
are required, the Contractor shall be responsible for submitting
treatment authorization requests to the mental health plan in the
child's county of origin. (Welf. & Inst. Code § 11376.)
C. When the Contractor is the mental health plan in the county of origin
for a child in AAP residing out of county with their adoptive parents
(Welf. & Inst. Code § 16125) or a child in Kin-GAP residing out of
county with their legal guardian (Welf. & Inst. Code § 11376) the
Contractor shall be responsible for authorization and reauthorization
of services for the child utilizing an expedited treatment
authorization process that meets the authorization requirements set
forth in MHSUDS Information Notice 19-026 and any applicable
Departmental notices issued after the effective date of this contract.
D. The Contractor shall comply with timelines specified in Cal. Code Regs.,
tit. 9, § 1830.220(b)(4)(A)(1-3) and requirements set forth in MHSUDS
Information Notice 19-026 and any applicable Departmental notices
issued after the effective date of this contract, when processing or
submitting authorization requests for children in a fester Gore AAP, or
Kinship Guardian AssistanGe Payment (Kin-GAP,) and Elide living outside
his or he-r their county of origin.
Inc GentFaEtOr shall use the standard forms issued by the Department,
the elentrenin equivalent of these forms generated from the Gentroetnr-s
EleGtrennG Health ReGQrd System, when a Ghild on a fester Gare aid-Godejs
Placed outside of his/heF GO inty of oriole The standard forms are•
j ClientAssessmcTr�
2) Q en��t DIen,
) SeFVOGe Authorization Reclaim
4) Clientssee_ssment Update,.
5) Progress 1�I�? Day-T-Featment intensive SerymG-
County of Fresno
17-94581 A01
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Exhibit A—Attachment 7 Al
ACCESS AND AVAILABILITY OF SERVICES
6) Progress Notesflays C?ehahilitat0en
7) Organizational Provider Agreement (Standard rnntront\
E. The ('entrantor may request an e)(empti n from us' the s rdard
si inh as a federal integrity agreement that prevents the use of the
standardized forms. ;e GeTtra r chill request this exemp inn fromthe
Department in writing
F. ne �'c CentraGter shall submit Ghanungesio its pFeGedures fer sepAng
beneficiaries plaoerd outside their GG unties of origin pursuant font to Welf. S2.
Inst. /o de-�+§ 14716
when these G o�ng s ffc eFc nt er/�mere of the
GORt[raGtVlTaenefi ri aGe�tft Of GO �nt`UT fhe�rtractG-r�
si omission shall also iRGI de significant Ghanges in the desnriptien of the
�au�-n-rr�rr�nurr-crr�v-rrr Gal-r�Gr-�arr�cTrTcrr��rc�Gri�rrvi-r-o-rm�.
Gontracter's prnced Tres for prev4ng out of plan services in accordance
with Gal Cede Rags tt., § 1�-�-1830.220 when a benefiGiary rpCtlyjYp�,
seniines or is placed in a cei inty net ceVered by the (`entracter's normal
pronerlWes
6. Indian Beneficiaries
The Contractor shall permit an Indian beneficiary who is eligible to receive
services from an Indian health care provider (IHCP) participating as a network
provider, to choose that IHCP as his or her provider, as long as that provider has
capacity to provide the services. (42 C.F.R. § 438.14(b)(3).) The Contractor shall
demonstrate it has sufficient IHCPs participating in its provider network to ensure
timely access to services available under the contract from such providers for
Indian beneficiaries who are eligible to receive services. (42 C.F.R. §
438.14(b)(1).) Contractor shall document good-faith efforts to contract with
all IHCPs in Contractor's county. If Contractor does not contract with a
IHCP in Contractor's county, Contractor must submit a written explanation
to the Department of why it failed to contract with that IHCP, with
supporting documentation. The Contractor shall permit Indian beneficiaries to
obtain covered services from out- of-network IHCPs if the beneficiaries are
otherwise eligible to receive such services. (42 C.F.R. § 438.14(b)(4).) The
Contractor shall permit an out-of-network IHCP to refer an Indian beneficiary to a
network provider. (42 C.F.R. § 438.14(b)(6).)
County of Fresno
17-94581 A01
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Exhibit A—Attachment 8 Al
PROVIDER NETWORK
1. Enrollment and Screening
A. The Contractor shall ensure that all network providers are enrolled with
the state as Medi-Cal providers consistent with the provider disclosure,
screening, and enrollment requirements of 42 Code of Federal
Regulations part 455, subparts B and E. (42 C.F.R. § 438.608(b).)
B. The Contractor may execute network provider agreements, pending the
outcome of screening, enrollment, and revalidation, of up to 120 days but
must terminate a network provider immediately upon determination that
the network provider cannot be enrolled, or the expiration of one 120 day
period without enrollment of the provider, and notify affected beneficiaries.
(42 C.F.R. § 438.602(b)(2).)
2. Assessment of Capacity
A. The Contractor shall implement mechanisms to assess the capacity of
service delivery for its beneficiaries. This includes monitoring the number,
type, and geographic distribution of mental health services within the
Contractor's delivery system.
B. The Contractor shall implement mechanisms to assess the accessibility of
services within its service delivery area. This shall include the
assessment of responsiveness of the Contractor's 24-hour toll-free
telephone number, timeliness of scheduling routine appointments,
timeliness of services for urgent conditions, and access to after-hours
care.
3. Network Adequacy
A. The Contractor shall ensure that all services covered under this Contract
are available and accessible to beneficiaries in a timely manner (42 C.F.R.
§ 438.206(a)).
B. Maintain and monitor a network of appropriate providers that is supported
by written agreements for subcontractors and that is sufficient to provide
adequate access to all services covered under this contract for all
beneficiaries, including those with limited English proficiency or physical or
mental disabilities. The Contractor shall ensure that network providers
County of Fresno
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Exhibit A—Attachment 8 Al
PROVIDER NETWORK
provide physical access, reasonable accommodations, and accessible
equipment for Medi-Cal beneficiaries with physical or mental disabilities.
(42 C.F.R. § 438.206(b)(1) and (c)(3).)
C. The Contractor shall adhere to, in all geographic areas within the county,
the time and distance standards for adult and pediatric mental health
providers, as specified in BHIN 20-023 and its attachments, or in
subsequent guidance issued in BHINs developed by the Department.
(42 C.F.R. § 438.68(a), (b)(1)(iii), (3), 438.206(a); Welf. & Inst. Code §
14197.)
D. The Contractor n4ay must submit to the Department a request for an
Alternate Access Standards upon notification that the Contractor is
deficient in network adequacy standards. The Department will evaluate
requests and grant appropriate exceptions to the state developed
standards, as specified in BHIN 20-023 and its attachments, or in
subsequent guidance issued by BHINs by the Department. (42 C.F.R.
§ 438.68(a), (d), 438.206(a); Welf. & Inst. Code § 14197).
E. The Contractor shall comply with network adequacy standards
developed by the Department to implement 42 C.F.R. §§ 438.68,
438.206, and 438.207, including provider ratios and other network
capacity requirements, as specified in BHIN 20-023 and its
attachments, or in subsequent guidance issued by BHIN by the
Department.
4. Timely Access
A. Timely Access. In accordance with 42 C.F.R. § 438.206(c)(1), the
Contractor shall: r+emnly with the requirements set forth in e
Regs tit Q §1810 And inGlurding the fell0wing:
1) Meet and require its providers to meet Department standards for
timely access to care and services, taking into account the urgency
of need for services, pursuant to Welf. & Inst. Code section
14197(d), as specified in BHIN 20-023 and its attachments, or
in subsequent, guidance issued by the Department.
2) Comply with the timeliness standards specified in Cal.;f,� Code
of Regulations., tit. 9, section 1810.405(c) and Welf. & Inst. Code §
County of Fresno
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Exhibit A—Attachment 8 Al
PROVIDER NETWORK
14717.1. Those standards apply to out-of-plan services, as well as
in-plan services.
3) Require subcontracted providers to have hours of operation during
which services are provided to Medi-Cal beneficiaries that are no
less than the hours of operation during which the provider offers
services to non-Medi-Cal beneficiaries. If the provider only serves
Medi-Cal beneficiaries, the Contractor shall require that hours of
operation are comparable to the hours the provider makes available
for Medi-Cal services that are not covered by the Contractor, or
another Mental Health Plan.
4) Make services available to beneficiaries 24 hours a day, 7 days a
week, when medically necessary.
5) Establish mechanisms to ensure that network providers comply
with the timely access requirements;
6) Monitor network providers regularly to determine compliance with
timely access requirements;
7) Take corrective action if there is a failure to comply with timely
access requirements by a network provider.
8) The timeliness standards speGified OR Gal.iferRia Code „f
Regulations., ji O seGtien 1810.405 and Welf. Inc+ ( o f:
147 r 1 apply +n a u+_nf_plaR senviGes, as well sOn_plri plan serV'Ges.
5. Documentation of Network Adequacy
A. The Contractor shall give assurances to the Department and provide
supporting documentation that demonstrates Contractor has the capacity
to serve the expected enrollment in its service area in accordance with
BHIN 20-023 and its attachments, or in subsequent guidance issued
by the Department. the Retw irk a deq land standards ideyeleped by the
Department as required by departmental g iidaRGe and reg Flo+inn. (42
C.F.R. § 438.207(a); Welf. & Inst. Code section 14197(f).)
B. The Contractor shall submit documentation to the Department, as
specified in BHIN 20-023 and its attachments, or in subsequent
guidance issued by the Department in a feFinat Specified h.. +ho
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Exhibit A—Attachment 8 Al
PROVIDER NETWORK
Department, to demonstrate that it complies with the following
requirements:
1) Offers an appropriate range of specialty services that are adequate
for the anticipated number of beneficiaries for the service area.
2) Maintains a network of providers that is sufficient in number, mix,
and geographic distribution to meet the needs of the anticipated
number of beneficiaries in the service area. (42 C.F.R. §
438.207(b).)
C. The Contractor shall submit the documentation at the times as specified
in BHIN 20-023 and its attachments, or in subsequent guidance
issued by the Department, but no less frequently than the following:
1) At the time it enters into this Contract with the Department;
2) On an annual basis; and
3) Within 10 business days of a significant change in the MHP's
operations that would affect the capacity and services,
including changes in Contractor services, benefits, geographic
service area, composition of, or payments to its provider
network; or enrollment of a new population. 42 C.F.R. §
438.207(c)(3)(i)(ii) At anti time there has been a sinnifinant
Ghannee rt as defined by the depament in Gentrantor's nneratlen f c•
that wee ild affect the ade`vi iaGy and nananity of seniiGes innli Jinn
the fellewipgL
a) A deGrease of 25 perGent or 11 in seniines or nreyiders
available to beneficiaries•
0
b) Ghanoes in benefits•
0
G) Chem,-- in geographin seFVFGe area;
d) Changes in +he Gnempnsitinn of or payments t
CE)RtrantC)r's provider network; er
County of Fresno
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Exhibit A—Attachment 8 Al
PROVIDER NETWORK
e) Enrollment of�a�n�/o�n i population in GentraGtnr'c GG inty (42F G.F.R..R. §438.207(G).);
f) Contractor is required to notify DHCS by email of one of
the listed changes at MHSDFinalRule(a)dhcs.ca.gov.
D. The Contractor shall include details regarding the change and Contractor's
plans to ensure beneficiaries continue to have access to adequate
services and providers.
6. Choice of Provider
The Contractor shall provide a beneficiary's choice of the person providing
services to the extent possible and appropriate consistent with Cal. Code Regs.,
tit. 9, §1830.225 and 42 Code of Federal Regulations part 438.3(I).
7. Provider Selection
A. The Contractor shall have written policies and procedures for selection
and retention of providers. (42 C.F.R. § 438.214(a).)
B. Contractor's policies and procedures for selection and retention of
providers must not discriminate against particular providers that serve
high-risk populations or specialize in conditions that require costly
treatment. (42 C.F.R. §§ 438.12(a)(2), 438.214(c).)
C. In all subcontracts with network providers, the Contractor must follow the
Department's uniform credentialing and re-credentialing policy. The
Contractor must follow a documented process for credentialing and re-
credentialing of network providers. (42 C.F.R. §§ 438.12(a)(2),
438.214(b).)
D. The Contractor shall not employ or subcontract with providers excluded
from participation in Federal health care programs under either section
1128 or section 1128A of the Act. (42 C.F.R. § 438.214(d).)
E. The Contractor may not discriminate in the selection, reimbursement, or
indemnification of any provider who is acting within the scope of his or her
County of Fresno
17-94581 A01
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Exhibit A—Attachment 8 Al
PROVIDER NETWORK
license or certification under applicable state law, solely on the basis of
that license or certification. (42 C.F.R. § 438.12(a)(1).)
F. The Contractor shall give practitioners or groups of practitioners who apply
to be MHP contract providers and with whom the MHP decides not to
contract written notice of the reason for a decision not to contract. (42
C.F.R. § 438.12(a)(1).)
G. Paragraphs A-F, above, may not be construed to:
1) Require the Contractor to subcontract with providers beyond the
number necessary to meet the needs of its beneficiaries;
2) Preclude the Contractor from using different reimbursement
amounts for different specialties or for different practitioners in the
same specialty; or
3) Preclude the Contractor from establishing measures that are
designed to maintain quality of services and control costs and are
consistent with its responsibilities to beneficiaries. (42 C.F.R. §
438.12(b).)
H. Upon request, Contractor shall demonstrate to the Department that its
providers are credentialed as required by paragraph C. (42 C.F.R. §
438.206(b)(6)
I. The Contractor shall establish individual, group and organizational
provider selection criteria as provided for in Cal. Code Regs., tit. 9, §
1810.435.
J. Contractor shall only use licensed, registered, or waivered providers
acting within their scope of practice for services that require a license,
waiver, or registration. (Cal. Code Regs., tit. 9, § 1840.314(d).)
K. The Contractor is not located outside of the United States. (42 C.F.R. §
602(i).)
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8. Provider Certification
A. The Contractor shall comply with Cal.ifGFRia Code of RegulatiORS., tit.le 9,
section 1810.435, in the selection of providers and shall review its
providers for continued compliance with standards at least once every
three years.
B. The Contractor shall comply with the provisions of 42 Code of Federal
Regulations, sections parts 455.104, 455.105, 1002.203 and 1002.3,
which relate to the provision of information about provider business
transactions and provider ownership and control, prior to entering into a
contract and during certification or re-certification of the provider.
C. "Satellite site" means a site owned, leased or operated by an
organizational provider at which specialty mental health services are
delivered to beneficiaries fewer than 20 hours per week, or, if located at a
multiagency site at which specialty mental health services are delivered by
no more than two employees or contractors of the provider.
D. The Contractor shall certify, or use another mental health plan's
certification documents to certify, the organizational providers that
subcontract with the Contractor to provide covered services in accordance
with Cal.l#ernwa Code of-Regulations., tit.le 9, section1810.435, and the
requirements specified prior to the date on which the provider begins to
deliver services under the contract, and once every three years after that
date. The on-site review required by CaLifern+a Code of Regulations.,
tit.le 9, section 1810.435(d), as a part of the certification process, shall be
made of any site owned, leased, or operated by the provider and used to
deliver covered services to beneficiaries, except that on-site review is not
required for public school or satellite sites.
E. The Contractor may allow an organizational provider to begin delivering
covered services to beneficiaries at a site subject to on-site review prior to
the date of the on-site review, provided the site is operational and has any
required fire clearances. The earliest date the provider may begin
delivering covered services at a site subject to on-site review is the latest
of these three (3) dates: 1) the date the provider's request for certification
is received by the Department in accordance with the Contractor's
certification procedures; 2) the date the site was operational; or 3) the date
a required fire clearance was obtained. The Contractor shall complete
any required on-site review of a provider's sites within six months of the
County of Fresno
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Exhibit A—Attachment 8 Al
PROVIDER NETWORK
date the provider begins delivering covered services to beneficiaries at the
site.
F. The Contractor may allow an organizational provider to continue delivering
covered services to beneficiaries at a site subject to on-site review as part
of the recertification process prior to the date of the on-site review,
provided the site is operational and has any required fire clearances. The
Contractor shall complete any required on-site review of a provider's sites
within six months of the date the recertification of the provider is due.
G. The Contractor and/or the Department shall each verify through an on-site
review that:
1) The organizational provider possesses the necessary license to
operate, if applicable, and any required certification.
2) The space owned, leased or operated by the provider and used for
services or staff meets local fire codes.
3) The physical plant of any site owned, leased, or operated by the
provider and used for services or staff is clean, sanitary, and in
good repair.
4) The organizational provider establishes and implements
maintenance policies for any site owned, leased, or operated by the
provider and used for services or staff to ensure the safety and
well-being of beneficiaries and staff.
5) The organizational provider has a current administrative manual
which includes: personnel policies and procedures, general
operating procedures, service delivery policies, any required state
or federal notices (DRA), and procedures for reporting unusual
occurrences relating to health and safety issues.
6) The organizational provider maintains client records in a manner
that meets the requirements of the Contractor, the requirements of
Attachment 10; Exhibit 2, Attachment 2, Section 11 and Section 13
Paragraph B; and applicable state and federal standards.
7) The organizational provider has sufficient staff to allow the
Contractor to claim federal financial participation (FFP) for the
services that the organizational provider delivers to beneficiaries,
County of Fresno
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Exhibit A—Attachment 8 Al
PROVIDER NETWORK
as described in Cal.+fern+a Code of Regulations., title 9, sections
1840.344 through 1840.358, as appropriate and applicable.
8) The organizational provider has written procedures for referring
individuals to a psychiatrist when necessary, or to a physician, if a
psychiatrist is not available.
9) The organizational provider's head or chief of service, as defined
Cal.0fernfa Code of Regulations., title 9, sections 622 through 630,
is a licensed mental health professional or other appropriate
individual as described in these sections.
10) For organizational providers that provide or store medications, the
provider stores and dispenses medications in compliance with all
pertinent state and federal standards. In particular:
a) All drugs obtained by prescription are labeled in compliance
with federal and state laws. Prescription labels are altered
only by persons legally authorized to do so.
b) Drugs intended for external use only and food stuffs are
stored separately from drugs intended for internal use.
c) All drugs are stored at proper temperatures: room
temperature drugs at 59-86 degrees Fahrenheit and
refrigerated drugs at 36-46 degrees Fahrenheit.
d) Drugs are stored in a locked area with access limited to
those medical personnel authorized to prescribe, dispense
or administer medication.
e) Drugs are not retained after the expiration date.
Intramuscular multi-dose vials are dated and initialed when
opened.
f) A drug log is maintained to ensure the provider disposes of
expired, contaminated, deteriorated and abandoned drugs in
a manner consistent with state and federal laws.
g) Policies and procedures are in place for dispensing,
administering and storing medications.
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Exhibit A—Attachment 8 Al
PROVIDER NETWORK
H. For organizational providers that provide day treatment intensive or day
rehabilitation, the provider has a written description of the day treatment
intensive and/or day rehabilitation program that complies with Attachment
2, Section 2 of this exhibit.
I. When an on-site review of an organizational provider would not otherwise
be required and the provider offers day treatment intensive and/or day
rehabilitation, the Contractor or the Department, as applicable, shall, at a
minimum, review the provider's written program description for compliance
with the requirements of Attachment 2, Section 2 of this exhibit.
J. On-site review is n-Gt required for hospital outpatient departments which
are operating under the license of the hospital. Services provided by
hospital outpatient departments may be provided either on the premises or
off-site.
K. On-site review is not required for primary care and psychological clinics,
as defined in Health and Safety Code section 1204.1 and licensed under
the Health and Safety Code. Services provided by the clinics may be
provided on the premises in accordance with the conditions of the clinic's
license.
L. When on-site review of an organizational provider is required, the
Contractor or the Department, as applicable, shall conduct an on-site
review at least once every three years. Additional certification reviews of
organizational providers may be conducted by the Contractor or
Department, as applicable, at its discretion, if-
1) The provider makes major staffing changes.
2) The provider makes organizational and/or corporate structure
changes (example: conversion to non-profit status).
3) The provider adds day treatment or medication support services
when medications are administered or dispensed from the provider
site.
4) There are significant changes in the physical plant of the provider
site (some physical plant changes could require a new fire
clearance).
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Exhibit A—Attachment 8 Al
PROVIDER NETWORK
5) There is a change of ownership or location.
6) There are complaints regarding the provider.
7) There are unusual events, accidents, or injuries requiring medical
treatment for clients, staff or members of the community.
M. The Contractor shall monitor the performance of its subcontractors on an
ongoing basis for compliance with the terms of this contract and shall
subject the subcontractors' performance to periodic formal review, at a
minimum in accordance with the recertification requirements. If the
Contractor identifies deficiencies or areas for improvement, the Contractor
and the subcontractor shall take corrective action.
N. In addition, Contractor may accept the certification of a provider by
another Mental Health Plan, or by the Department, in order to meet the
Contractor's obligations under Attachment 8, Sections 7 and 8. However,
regardless of any such delegation to a subcontracting entity or acceptance
of a certification by another MHP.
9. Provider Beneficiary Communications
A. The Contractor shall not prohibit nor otherwise restrict, a licensed,
waivered, or registered professional, as defined in Cal. a Code of
RegulatieRs., tit.le 9, sections 1810.223 and 1810.254, who is acting
within the lawful scope of practice , from advising or advocating on behalf
of a beneficiary for whom the provider is providing mental health services
for any of the following:
1) The beneficiary's health status, medical care, or treatment options,
including any alternative treatment that may be self-administered;
2) Information the beneficiary needs in order to decide among all
relevant treatment options;
3) The risks, benefits, and consequences of receiving treatment or not
receiving treatment; and
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PROVIDER NETWORK
4) The beneficiary's right to participate in decisions regarding his or
her health care, including the right to refuse treatment, and to
express preferences about future treatment decisions. (42 C.F.R. §
438.102(a)(1).)
10. Provider Notifications
A. The Contractor shall inform providers and subcontractors, at the time they
enter into a contract, about:
1) Beneficiary grievance, appeal, and fair hearing procedures and
timeframes as specified in 42 C.F.R. 438.400 through 42 C.F.R.
438.424.
2) The beneficiary's right to file grievances and appeals and the
requirements and timeframes for filing.
3) The availability of assistance to the beneficiary with filing
grievances and appeals.
4) The beneficiary's right to request a State fair hearing after the
Contractor has made a determination on a beneficiary's appeal,
which is adverse to the beneficiary.
5) The beneficiary's right to request continuation of benefits that the
Contractor seeks to reduce or terminate during an appeal or state
fair hearing filing, if filed within the allowable timeframes, although
the beneficiary may be liable for the cost of any continued benefits
while the appeal or state fair hearing is pending if the final decision
is adverse to the beneficiary.
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Exhibit A—Attachment 9 Al
DOCUMENTATION REQUIRMENTS
1. Documentation Standards
The Contractor shall set standards and implement processes that will support
understanding of, and compliance with, documentation standards set forth in this
section and any standards set by the Contractor. The Contractor may monitor
performance so that the documentation of care provided will satisfy the
requirements set forth below. The documentation standards for beneficiary care
are minimum standards to support claims for the delivery of specialty mental
health services. All standards shall be addressed in the beneficiary record;
however, there is no requirement that the records have a specific document or
section addressing these topics.
A. Assessment
1) The Contractor shall ensure that the following areas are included,
as appropriate, as part of a comprehensive beneficiary record when
an assessment has been performed. For children or certain other
beneficiaries unable to provide a history, this information may be
obtained from the parents/care-givers, etc.
a) Presenting Problem. The beneficiary's chief complaint,
history of the presenting problem(s), including current level
of functioning, relevant family history and current family
information;
b) Relevant conditions and psychosocial factors affecting the
beneficiary's physical health and mental health; including, as
applicable, living situation, daily activities, social support,
cultural and linguistic factors and history of trauma or
exposure to trauma;
c) Mental Health History. Previous treatment, including
providers, therapeutic modality (e.g., medications,
psychosocial treatments) and response, and inpatient
admissions. If possible, include information from other
sources of clinical data, such as previous mental health
records, and relevant psychological testing or consultation
reports;
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Exhibit A—Attachment 9 Al
DOCUMENTATION REQUIRMENTS
d) Medical History. Relevant physical health conditions
reported by the beneficiary or a significant support person.
Include name and address of current source of medical
treatment. For children and adolescents, the history must
include prenatal and perinatal events and relevant/significant
developmental history. If possible, include other medical
information from medical records or relevant consultation
reports;
e) Medications. Information about medications the beneficiary
has received, or is receiving, to treat mental health and
medical conditions, including duration of medical treatment.
The assessment shall include documentation of the absence
or presence of allergies or adverse reactions to medications,
and documentation of an informed consent for medications;
f) Substance Exposure/Substance Use. Past and present use
of tobacco, alcohol, caffeine, CAM (complementary and
alternative medications) and over-the-counter, and illicit
drugs;
g) Client Strengths. Documentation of the beneficiary's
strengths in achieving client plan goals related to the
beneficiary's mental health needs and functional
impairments as a result of the mental health diagnosis;
h) Risks. Situations that present a risk to the beneficiary and/or
others, including past or current trauma;
i) A mental status examination;
j) A complete diagnosis from the most current DSM, or a
diagnosis from the most current ICD-code shall be
documented, consistent with the presenting problems,
history, mental status examination and/or other clinical data;
and,
k) Additional clarifying formulation information, as needed.
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Exhibit A—Attachment 9 Al
DOCUMENTATION REQUIRMENTS
2) Timeliness/Frequency Standard for Assessment. The Contractor
shall establish written standards for timeliness and frequency for
the elements identified in item A of this section.
B. Client Plans
1) The Contractor shall ensure that Client Plans:
a) Have specific observable and/or specific quantifiable
goals/treatment objectives related to the beneficiary's mental
health needs and functional impairments as a result of the
mental health diagnosis;
b) Identify the proposed type(s) of intervention/modality
including a detailed description of the intervention to be
provided;
c) Have a proposed frequency and duration of intervention(s);
d) Have interventions that focus and address the identified
functional impairments as a result of the mental disorder
(from Cal. Code Regs., tit. 9, § 1830.205(b)); have
interventions that are consistent with the client plan goal;
e) Be consistent with the qualifying diagnoses;
f) Be signed (or electronic equivalent) by:
i. The person providing the service(s), or,
ii. A person representing a team or program providing
services, or
iii. A person representing the Contractor providing
services; or
iv. By one of the following as a co-signer, if the client plan
is used to establish that services are provided under the
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Exhibit A—Attachment 9 Al
DOCUMENTATION REQUIRMENTS
direction of an approved category of staff, and if the
signing staff is not of the approved category:
a) A physician,
b) A licensed/waivered psychologist,
c) A licensed/registered/waivered social worker,
d) A licensed/registered/waivered marriage and
family therapist, or
e) A registered nurse, including but not limited to
nurse practitioners, and clinical nurse
specialists.
g) Include documentation of the beneficiary's participation in
and agreement with the client plan, as described in Cal.
Code Regs., tit. 9, § 1810.440(c)(2)(A)(B).
i. Examples of acceptable documentation include, but
are not limited to, reference to the beneficiary's
participation and agreement in the body of the plan,
beneficiary signature on the plan, or a description of
the beneficiary's participation and agreement in the
client record;
ii. The beneficiary's signature or the signature of the
beneficiary's legal representative is required on the
client plan when:
a) The beneficiary is expected to be in long term
treatment as determined by the MHP and,
b) The client plan provides that the beneficiary will
be receiving more than one type of specialty
mental health service;
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Exhibit A—Attachment 9 Al
DOCUMENTATION REQUIRMENTS
iii. When the beneficiary's signature or the signature of
the beneficiary's legal representative is required on
the client plan and the beneficiary refuses or is
unavailable for signature, the client plan shall include
a written explanation of the refusal or unavailability.
2) There shall be documentation in the client plan that a copy of the
client plan was offered to the beneficiary.
3) The client plan shall be updated at least annually, or when there
are significant changes in the beneficiary's condition.
C. Progress Notes
1) The Contractor shall ensure that progress notes describe how
services provided reduced impairment, restored functioning, or
prevented significant deterioration in an important area of life
functioning outlined in the client plan. Items that shall be contained
in the client record related to the beneficiary's progress in treatment
include:
a) Timely documentation of relevant aspects of beneficiary
care, including documentation of medical necessity;
b) Documentation of beneficiary encounters, including relevant
clinical decisions, when decisions are made, alternative
approaches for future interventions;
c) Interventions applied, beneficiary's response to the
interventions and the location of the interventions;
d) The date the services were provided;
e) Documentation of referrals to community resources and
other agencies, when appropriate;
f) Documentation of follow-up care, or as appropriate, a
discharge summary; and
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DOCUMENTATION REQUIRMENTS
g) The amount of time taken to provide services; and
h) The signature of the person providing the service (or
electronic equivalent); the person's type of professional
degree, licensure, or job title.
2) Timeliness/Frequency of Progress Notes. Progress notes shall be
documented at the frequency by type of service indicated below:
a) Every Service Contact:
i. Mental Health Services;
ii. Medication Support Services;
iii. Crisis Intervention;
iv. Targeted Case Management;
b) Daily:
i. Crisis Residential;
ii. Crisis Stabilization (1 x/23hr);
iii. Day Treatment Intensive; and
c) Weekly:
i. Day Treatment Intensive: a clinical summary
reviewed and signed by a physician, a
licensed/waivered psychologist, clinical social worker,
or marriage and family therapist; or a registered nurse
who is either staff to the day treatment intensive
program or the person directing the service;
ii. Day Rehabilitation;
iii. Adult Residential.
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Exhibit A—Attachment 9 Al
DOCUMENTATION REQUIRMENTS
D. Other
1) All entries to the beneficiary record shall be legible.
2) All entries in the beneficiary record shall include:
a) The date of service;
b) The signature of the person providing the service (or
electronic equivalent); the person's type of professional
degree, licensure or job title; and the relevant identification
number, if applicable.
c) The date the documentation was entered in the beneficiary
record.
3) The Contractor shall have a written definition of what constitutes a
long term care beneficiary.
4) Contractor shall require providers to obtain and retain a written
medication consent form signed by the beneficiary agreeing to the
administration of psychiatric medication. This documentation shall
include, but not be limited to, the reasons for taking such
medications; reasonable alternative treatments available, if any; the
type, range of frequency and amount, method (oral or injection),
and duration of taking the medication; probable side effects;
possible additional side effects which may occur to beneficiaries
taking such medication beyond three (3) months; and that the
consent, once given, may be withdrawn at any time by the
beneficiary.
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Exhibit A—Attachment 10 Al
COORDINATION AND CONTINUITY OF CARE
1. Coordination of Care
A. The Contractor shall implement procedures to deliver care to and
coordinate services for all of its beneficiaries. (42 C.F.R. § 438.208(b).)
These procedures shall meet Department requirements and shall do the
following:
1) Ensure that each beneficiary has an ongoing source of care
appropriate to his or her needs and a person or entity formally
designated as primarily responsible for coordinating the services
accessed by the beneficiary. The beneficiary shall be provided
information on how to contact their designated person or entity. (42
C.F.R. § 438.208(b)(1).)
2) Coordinate the services the Contractor furnishes to the beneficiary
between settings of care, including appropriate discharge planning
for short term and long-term hospital and institutional stays.
Coordinate the services the Contractor furnishes to the beneficiary
with the services the beneficiary receives from any other managed
care organization, in FFS Medicaid, from community and social
support providers, and other human services agencies used by its
beneficiaries. (42 C.F.R. § 438.208(b)(2)(i)-(iv), Cal. Code Regs.,
tit. 9 § 1810.415.)
3) The Contractor shall share with the Department or other managed
care entities serving the beneficiary the results of any identification
and assessment of that beneficiary's needs to prevent duplication
of those activities. (42 C.F.R. § 438.208(b)(4).)
4) Ensure that each provider furnishing services to beneficiaries
maintains and shares, as appropriate, a beneficiary health record in
accordance with professional standards. (42 C.F.R. §
438.208(b)(5).)
5) Ensure that, in the course of coordinating care, each beneficiary's
privacy is protected in accordance with all federal and state privacy
laws, including but not limited to 45 C.F.R. § 160 and § 164,
subparts A and E, to the extent that such provisions are applicable.
(42 C.F.R. § 438.208(b)(6).)
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Exhibit A—Attachment 10 Al
COORDINATION AND CONTINUITY OF CARE
B. The Contractor shall enter into a Memorandum of Understanding (MOU)
with any Medi-Cal managed care plan serving the Contractor's
beneficiaries. The Contractor shall notify the Department in writing if the
Contractor is unable to enter into an MOU or if an MOU is terminated,
providing a description of the Contractor's good faith efforts to enter into or
maintain the MOU. The MHP shall monitor the effectiveness of its MOU
with Medi-Cal managed care plans. (Cal. Code Regs., tit. 9, § 1810.370.)
C. The Contractor shall implement a transition of care policy that is in
accordance with applicable state and federal regulations, Mental
Health and Substance Use Disorder Services Information Notice 18-
059 and any Behavioral Health Information Notices issued by the
Department for parity in mental health and substance use disorder
benefits subsequent to the effective date of this contract and
GOMplles with the Department's traRSitlen of Gore pellc . (42 C.F.R. §
438.62(b)(1)-(2).)
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Exhibit A—Attachment 11 Al
INFORMATION REQUIREMENTS
1. Basic Requirements
A. The Contractor shall provide information in a manner and format that is
easily understood and readily accessible to beneficiaries. (42 C.F.R. §
438.10(c)(1).) The Contractor shall provide all written materials for
beneficiaries in easily understood language, format, and alternative
formats that take into consideration the special needs of beneficiaries in
compliance with—. (42 C.F.R. § 438.10(d)(6).3 The Contractor shall inform
beneficiaries that information is available in alternate formats and how to
access those formats in compliance with—. (42 C.F.R. § 438.10.4
B. The Contractor shall provide the required information in this section to
each beneficiary when first receiving specialty mental health services and
upon request. (1915(b) Medi-Cal Specialty Mental Health Services
Waiver, § (2), subd. (d), at p. 26., attachments 3, 4; Cal. Code Regs., tit. 9,
§ 1810.360(e).)
C. The Contractor shall operate a website that provides the content required
in this section and complies with the requirements in—. (42 C.F.R. §
438.10.4
D. For consistency in the information provided to beneficiaries, the Contractor
shall use the Department developed definitions for managed care
terminology, including: appeal, excluded services, grievance,
hospitalization, hospital outpatient care, medically necessary, network,
non-participating provider, physician services, plan, preauthorization,
participating provider, provider, skilled nursing care, and urgent care. (42
C.F.R. 438.10(c)(4)(i).)
E. The Contractor shall use Department developed model beneficiary
handbooks and beneficiary notices that describe the transition of care
policies for beneficiaries. (42 C.F.R. §§ 438.10(c)(4)(ii), 438.62(b)(3).)
F. Beneficiary information required in this section may only be provided
electronically by the Contractor if all of the following conditions are met:
1) The format is readily accessible;
2) The information is placed in a location on the Contractor's website
that is prominent and readily accessible;
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Exhibit A—Attachment 11 Al
INFORMATION REQUIREMENTS
3) The information is provided in an electronic form which can be
electronically retained and printed;
4) The information is consistent with the content and language
requirements of this Attachment; and
5) The beneficiary is informed that the information is available in paper
form without charge upon request and Contractor provides it upon
request within 5 business days. (42 C.F.R. § 438.10(c)(6).)
G. The Contractor shall have in place mechanisms to help beneficiaries and
potential beneficiaries understand the requirements and benefits of the
plan. (42 C.F.R. § 438.10(c)(7).)
2. Information Provided to Beneficiaries
A. The Contractor shall provide information to beneficiaries and potential
beneficiaries including, at a minimum, all of the following:
1) The basic features of managed care. (42 C.F.R. § 438.10(e)(2)(ii).)
2) The mandatory enrollment process. (42 C.F.R. § 438.10(e)(2)(iii).)
3) The service area covered by the Contractor. (42 C.F.R. §
438.10(e)(2)(iv).)
4) Covered benefits, including:
a. Which benefits are provided by the Contractor; and,
b. Which, if any, benefits are provided directly by the State.
5) The provider directory. (42 C.F.R. § 438.10(e)(2)(vi).)
6) Any cost-sharing that will be imposed by the Contractor consistent
with the State Plan. (42 C.F.R. §§ 438.10(e)(2)(vii); State Plan §
4.18.)
7) The requirements for the Contractor to provide adequate access to
covered services, including the network adequacy standards
County of Fresno
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Exhibit A—Attachment 11 Al
INFORMATION REQUIREMENTS
established in 42 Code of Federal Regulations part 438.68. (42
C.F.R. § 438.10(e)(2)(viii).)
8) The Contractor's responsibilities for coordination of care. (42 C.F.R.
§ 438.10(e)(2)(ix).)
9) To the extent available, quality and performance indicators for the
Mental Health Plan, including beneficiary satisfaction. (42 C.F.R. §
438.10(e)(2)(x).)
B. The Contractor shall make a good faith effort to give written notice of
termination of a contracted provider, within 15 naleRdar days aftor ronoipt
or iss ianno of the tormina+inn n„+iGe, to each beneficiary who was seen
on a regular basis by the terminated provider. The notice to the
beneficiary shall be provided 30 calendar days prior to the effective
date of the termination or 15 calendar days after receipt or issuance
of the termination notice, whichever is later. (42 C.F.R. § 438.10(f)(1).)
3. Language and Format
A. The Contractor shall provide all written materials for potential beneficiaries
and beneficiaries in a font size no smaller than 12 point. (42 C.F.R.
438.10(d)(6)(ii).)
B. The Contractor shall ensure its written materials that are critical to
obtaining services are available in alternative formats, moll diRg laroo
Wit, upon request of the potential beneficiary or beneficiary at no cost.
Large print moans printed in a font size no smaller than 18 point Written
material that are critical to obtaining services include, at a minimum,
provider directories, beneficiary handbooks, appeal and grievance
notices, denial and termination notices, and Contractor's mental
health education materials. (42 C.F.R. § 438.10(d)(3).)
C. The Contractor shall make its written materials that are critical to obtaining
services, including, at a minimum, provider directories, beneficiary
handbooks, appeal and grievance notices, denial and termination notices,
and Contractor's mental health education materials, available in the
prevalent non-English languages in the county. (42 C.F.R. § 438.10(d)(3).)
1) The Contractor shall notify beneficiaries, prospective
beneficiaries, and members of the public that written translation
County of Fresno
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Exhibit A—Attachment 11 Al
INFORMATION REQUIREMENTS
is available in prevalent languages free of cost and how to access
those materials. (42 C.F.R. § 438.10(d)(5)(i), (iii); Welf. & Inst.
Code § 14727(a)(1); Cal. Code Regs. tit. 9 § 1810.410, subd. (e),
para. (4).)
2) The CentragtOF shall in irde t linos in the prevalent non English
�T�c-vvrrcrac �riurrrrT cvurcrr vrr
languages in the state as well as large print explaining the
availability of written translation or oral interpretation to understand
the information provided. (42 G.F.Q. § 438fir
3) The GenTtrra r shall inGli de taglines in the prevalent nGR Cn�T
languages n trr he state as well as large print explaining the
availability of the tell free and Teletypewriter Telephone/Text
Telephone (TTV/TDY) telephone number of the Gentrantor's
membeF/GUStGMeF SeFViGe ''nit (42 G.F.R. § 438.1 n(fir!)(3T7
4\ The GentragtOF shall netify hep�r+iories that written tronsloieR s
r�rnc-vvrnrcrc �riurrr-rv` �J "'cr-r �.r c-w-rr crr�crarrrr�
available in prevalent languages free of nest and shall netifii
baaefigiaries hew to QEGescthesrry e materials. (42 C.F.R. f.
43 81 0(d)(�5)(i) /iii\• Cal Cede-Regs., tit Q § 1810.410, subd. (e)
5) Prevalent non-English language means a language identified as the
primary language of 3,000 beneficiaries or five percent of the
beneficiary population (whichever is lower) in the Contractor's
service area as indicated on MEDs. (42 C.F.R. § 438.10(a), Cal.
Code Regs., tit. 9, § 1810.410, subd. (a), para. (3).)
D. The Contractor shall make auxiliary aids and services available upon
request and free of charge to each beneficiary. (42 C.F.R. § 438.10(d)(3)-
(4).) Contractor shall also notify beneficiaries, prospective beneficiaries,
and members of the public that these services are available free of
charge and how to access these services. (42 C.F.R. § 438.10(d) (5)(ii)-
(iii); Welf. & Inst. Code § 14727(a)(2).)
E. The Contractor shall make oral interpretation and auxiliary aids, such as
Teletypewriter Telephone/Text Telephone (TTY/TDYj and American
Sign Language (ASL), available and free of charge for any language. (42
C.F.R. § 438.10(d)(2), (4)-(5).) Contractor shall notify beneficiaries:
prospective beneficiaries, and members of the public that these
services are4s available free of charge and how to access theese
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Exhibit A—Attachment 11 Al
INFORMATION REQUIREMENTS
services. (42 C.F.R. § 438.10(d)(5)(i), (iii); Welf. & Inst. Code §
14727(a)(1)-(2).)
F. Nondiscrimination Notice and Taglines
1) The Contractor shall post (1) a Department-approved
nondiscrimination notice and (2) language taglines in a
conspicuously visible font size in English in the top 15 non-English
lanquages in the State, and any other languages, as determined by
the Department, explaining the availability of free language
assistance services, including written translation and oral
interpretation, and information on how to request auxiliary aids and
services, including materials in alternative formats. The
nondiscrimination notice and taglines, shall include the toll-free and
TTY/TDY telephone number of the Contractor's member/customer
service unit for obtaining these services, and shall be posted as
follows:
a) In a-14 conspicuous physical locations where the
Contractor interacts with the public;
b) On the internet website published and maintained by the
Contractor, in a manner that allows beneficiaries,
prospective beneficiaries, and members of the public to
easily locate the information; and
c) In the beneficiary handbook, all materials critical to
obtaining services, and informational notices targeted to
beneficiaries and members of the public (including
notices of action). (42 C.F.R. § 438.10(d)(2)-(3); Welf. &
Inst. Code, § 14727(b), (c)(1)-(2).)
2) The Contractor's nondiscrimination notice and language
taglines must be in a conspicuously visible font size no
smaller than 12 point. (42 C.F.R. § 438.10(d)(3), (d)(6)(ii).)
3) The Contractor shall provide information to all beneficiaries,
prospective beneficiaries, and members of the public on how to file a
Discrimination Grievance with:
a) The Contractor and the Department if there is a concern
of discrimination based on sex, race, color, religion,
County of Fresno
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Exhibit A—Attachment 11 Al
INFORMATION REQUIREMENTS
ancestry, national origin, ethnic group identification, acre,
mental disability, physical disability, medical condition,
genetic information, marital status, gender, gender
identity, or sexual orientation. (Welf. & Inst. Code §
14727(a)(4).)
b) The United States Department of Health and Human
Services Office for Civil Rights if there is a concern of
discrimination based on race, color, national origin, sex,
age, or disability. (Welf. & Inst. Code § 14727(a)(5).)
4. Handbook
A. The Contractor shall provide beneficiaries with a copy of the handbook
and provider directory when the beneficiary first accesses services and
thereafter upon request. (Cal. Code Regs., tit. 9, § 1810.360.)
B. The Contractor shall ensure that the handbook includes the current toll-
free telephone number(s) that provides information in threshold languages
and is available twenty-four hours a day, seven days a week. (Cal. Code
Regs., tit. 9, § 1810.405, subd. (d).)
C. The beneficiary handbook shall include information that enables the
beneficiary to understand how to effectively use the managed care
program. This information shall include, at a minimum-
1) Benefits provided by the Contractor. (42 C.F.R. § 438.10(g)(2)(i).)
2) How and where to access any benefits provided by the Contractor,
including any cost sharing, and how transportation is provided. (42
C.F.R. § 438.10(g)(2)(ii).)
a) The amount, duration, and scope of benefits available under
the Contract in sufficient detail to ensure that beneficiaries
understand the benefits to which they are entitled. (42
C.F.R. § 438.10(g)(2)(iii).)
b) Procedures for obtaining benefits, including any
requirements for service authorizations and/or referrals for
specialty care and for other benefits not furnished by the
beneficiary's provider. (42 C.F.R. § 438.10(g)(2)(iv).)
County of Fresno
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Exhibit A—Attachment 11 Al
INFORMATION REQUIREMENTS
c) Any restrictions on the beneficiary's freedom of choice
among network providers. (42 C.F.R. § 438.10(g)(2)(vi).)
d) The extent to which, and how, beneficiaries may obtain
benefits from out-of-network providers. (42 C.F.R. §
438.10(g)(2)(vii).)
e) Cost sharing, if any, consistent with the State Plan. (42
C.F.R. § 438.10(g)(2)(viii); State Plan § 4.18.)
f) Beneficiary rights and responsibilities, including the
elements specified in § 438.100 as specified in Section 7 of
this Attachment. (42 C.F.R. § 438.10(g)(2)(ix).)
g) The process of selecting and changing the beneficiary's
provider. (42 C.F.R. § 438.10(g)(2)(x).)
h) Grievance, appeal, and fair hearing procedures and
timeframes, consistent with 42 C.F.R. §§ 438.400 through
438.424, in a state-developed or state-approved description.
Such information shall include:
1) The right to file grievances and appeals;
i. The Contractor shall include information on
filing a Discrimination Grievance with the
Contractor, the Department's Office of Civil Rights
and the U.S. Health and Human Services Office for
Civil Rights, and shall specifically include
information stating that the Contractor complies
with all state and federal civil rights laws. If a
beneficiary believes they have been unlawfully
discriminated against, they have the right to file a
Discrimination Grievance with the Contractor, the
Department's Office of Civil Rights, and the
United States Department of Health and Human
Services, Office for Civil Rights.
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Exhibit A—Attachment 11 Al
INFORMATION REQUIREMENTS
2) The requirements and timeframes for filing a
grievance or appeal;
3) The availability of assistance in the filing process;
4) The right to request a state fair hearing after the
Contractor has made a determination on a
beneficiary's appeal which is adverse to the
beneficiary;
5) The fact that, when requested by the beneficiary,
benefits that the Contractor seeks to reduce or
terminate will continue if the beneficiary files an
appeal or a request for state fair hearing within the
timeframes specified for filing, and that the beneficiary
may, consistent with state policy, be required to pay
the cost of services furnished while the appeal or
state fair hearing is pending if the final decision is
adverse to the beneficiary. (42 C.F.R. §
438.10(g)(2)(xi).)
i) How to exercise an advance directive, as set forth in 42
C.F.R. 438.30). (42 C.F.R. § 438.10(g)(2)(xii).)
D How to access auxiliary aids and services, including
additional information in in alternative formats or languages.
(42 C.F.R. § 438.10(g)(2)(xiii).)
k) The Contractor's toll-free telephone number for member
services, medical management, and any other unit providing
services directly to beneficiaries. (42 C.F.R. §
438.10(g)(2)(xi v).)
I) Information on how to report suspected fraud or abuse. (42
C.F.R. § 438.10(g)(2)(xv).)
m) Additional information that is available upon request,
includes the following:
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Exhibit A—Attachment 11 Al
INFORMATION REQUIREMENTS
1) Information on the structure and operation of the
Contractor.
2) Physician incentive plans as set forth in 42 C.F.R. §
438.3(i). (42 C.F.R. § 438.10(f)(3).)
D. The Contractor shall give each beneficiary notice of any significant change
(as defined by the Department) to information in the handbook at least 30
days before the intended effective date of the change. (42 C.F.R. §
438.10(g)(4).)
E. Consistent with 42 Code of Federal Regulations part 438.10(g)(3) and
Cal. a Code of Regela#+eRs., tit.le 9, section 1810.360, subdivision (e),
the handbook will be considered provided if the Contractor:
1) Mails a printed copy of the information to the beneficiary's mailing
address before the beneficiary first receives a specialty mental
health service;
2) Mails a printed copy of the information upon the beneficiary's
request to the beneficiary's mailing address;
3) Provides the information by email after obtaining the beneficiary's
agreement to receive the information by email;
4) Posts the information on the Contractor's website and advises the
beneficiary in paper or electronic form that the information is
available on the internet and includes the applicable internet
addresses, provided that beneficiaries with disabilities who cannot
access this information online are provided auxiliary aids and
services upon request at no cost; or,
5) Provides the information by any other method that can reasonably
be expected to result in the beneficiary receiving that information. If
the Contractor provides the handbook in-person when the
beneficiary first receives specialty mental health services, the date
and method of delivery shall be documented in the beneficiary's
file.
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INFORMATION REQUIREMENTS
5. Provider Directory
A. The Contractor must follow the Department's provider directory
policy, which the Department implemented via Mental Health and
Substance Use Disorder Services Information Notice 18-020, and
other applicable Mental Health and Substance Use Disorder Services
Information Notices that may be issued subsequent to the effective
date of this contract.
B. The Contractor shall make provider directories available in electronic and
paper form upon request, and ensure that the provider directories include
the following information for all network providers, including each
licensed, waivered, or registered mental health provider employed by
the Contractor, each provider organization or individual practitioner
contracting with the Contractor, and each licensed, waivered, or
registered mental health provider employed by a provider
organization to deliver Medi-Cal services:
1) Information on the category or categories of services available from
each provider. (42 C.F.R. § 438.10(h)(1)(v).)
2) The names, any group affiliations, street addresses, telephone
numbers, specialty, and website URLs of current contracted
providers by category. (42 C.F.R. § 438.10(h)(1)(i)-(v).)
3) The cultural and linguistic capabilities of network providers,
including languages (including ASL) offered by the provider or a
skilled medical interpreter at the provider's office, and whether the
provider has rmmpleted nUltural GGMpetenGe training (42 C.F.R. §
438.10(h)(1)(vii).)
4) Whether network providers' offices/facilities have accommodations
for people with physical disabilities, including offices, exam room(s)
and equipment. (42 C.F.R. § 438.10(h)(1)(viii).)
5) A means to identify which providers are accepting new
beneficiaries. (42 C.F.R. § 438.10(h)(1)(vi).)
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INFORMATION REQUIREMENTS
6) Type of practitioner as appropriate.
7) National Provider Identifier number.
8) California License number and type of license.
9) Whether the provider has completed cultural competence
training.
C. Information included in a paper provider directory shall be updated at least
monthly and electronic provider directories shall be updated no later than
30 calendar days after the Contractor receives updated provider
information. Contractor shall ensure processes are in place to allow
providers to promptly verify or submit changes to the information
required to be in the directory. (42 C.F.R. § 438.10(h)(3).)
D. Provider directories shall be made available on the Contractor's website in
a machine readable file and format as specified by the Secretary. (42
C.F.R. § 438.10(h)(4).)
6. Advance Directives
A. For purposes of this contract, advance directives means a written
instruction, such as a living will or durable power of attorney for health
care, recognized under California law, relating to the provision of health
care when the individual is incapacitated. (42 C.F.R. § 489.100.)
B. The Contractor shall maintain written policies and procedures on advance
directives, which include a description of applicable California law. (42
C.F.R. §§ and 438.3(j)(1)-(3), 422.128). Any written materials prepared by
the Contractor for beneficiaries shall be updated to reflect changes in state
laws governing advance directives as soon as possible, but no later than
90 days after the effective date of the change. (42 C.F.R. § 438.30)(4).)
C. The Contractor shall provide adult beneficiaries with the written
information on advance directives. (42 C.F.R. § 438.30)(3).)
D. The Contractor shall not condition the provision of care or otherwise
discriminate against an individual based on whether or not the individual
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Exhibit A—Attachment 11 Al
INFORMATION REQUIREMENTS
has executed an advance directive. (42 C.F.R. §§ 422.128(b)(1)(ii)(F),
438.3(j).)
E. The Contractor shall educate staff concerning its policies and procedures
on advance directives. (42 C.F.R. §§ 422.128(b)(1)(ii)(H), 438.3(j).)
7. Beneficiary Rights
A. The parties to this contract shall comply with applicable laws and
regulations relating to patients' rights, including but not limited to Wel. &
Inst. Code 5325, Cal.0ferRia Code of RegulatiORS., tit.le 9, sections 862
through 868, and 42 Code of Federal Regulations section 438.100. The
Contractor shall ensure that its subcontractors comply with all applicable
patients' rights laws and regulations.
B. The Contractor shall have written policies regarding the beneficiary rights
specified in this section and ensure that its staff, subcontractors, and
providers take those rights into account when providing services, including
the right to:
1) Receive information in accordance with 42 C.F.R. § 438.10. (42
C.F.R. § 438.100(b)(2)(i).)
2) Be treated with respect and with due consideration for his or her
dignity and privacy. (42 C.F.R. § 438.100(b)(2)(ii).)
3) Receive information on available treatment options and
alternatives, presented in a manner appropriate to the beneficiary's
condition and ability to understand. (42 C.F.R. § 438.100(b)(2)(iii).)
4) Participate in decisions regarding his or her health care, including
the right to refuse treatment. (42 C.F.R. § 438.100(b)(2)(iv).)
5) Be free from any form of restraint or seclusion used as a means of
coercion, discipline, convenience, or retaliation. (42 C.F.R. §
438.100(b)(2)(v).)
6) Request and receive a copy of his or her medical records, and to
request that they be amended or corrected. (42 C.F.R. §
438.100(b)(2)(vi); 45 C.F.R. §§ 164.524,164.526.)
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INFORMATION REQUIREMENTS
7) Be furnished services in accordance with 42 C.F.R. §§ 438.206
through 438.210. (42 C.F.R. § 438.100(b)(3).)
8) Freely exercise his or her rights without adversely affecting the way
the, Contractor, subcontractor, or provider treats the beneficiary.
(42 C.F.R. § 438.100(c).)
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1. General Provisions
A. The Contractor shall have a grievance and appeal system in place for
beneficiaries. (42 C.F.R. §§ 438.228(a), 438.402(a); Cal. Code Regs., tit.
9, § 1850.205.) The grievance and appeal system shall be implemented to
handle appeals of adverse benefit determinations and grievances, and
shall include processes to collect and track information about them. The
Contractor's beneficiary problem resolution processes shall include:
1) A grievance process;
2) An appeal process; and,
3) An expedited appeal process. (Cal. Code Regs., tit. 9, §
1850.205(b)(1)-(b)(3).)
B. For the grievance, appeal, and expedited appeal processes, the
Contractor shall comply with the following requirements:
1) The Contractor shall ensure that each beneficiary has adequate
information about the Contractor's problem resolution processes by
taking at least the following actions:
a) Including information describing the grievance, appeal, and
expedited appeal processes in the Contractor's beneficiary
booklet and providing the beneficiary handbook to
beneficiaries as described in Attachment 11 of this contract.
(Cal. Code Regs., tit. 9, § 1850.205(c)(1)(A).)
b) Posting notices explaining grievance, appeal, and expedited
appeal process procedures in locations at all Contractor
provider sites. Notices shall be sufficient to ensure that the
information is readily available to both beneficiaries and
provider staff. The posted notice shall also explain the
availability of fair hearings after the exhaustion of an appeal
or expedited appeal process, including information that a fair
hearing may be requested whether or not the beneficiary has
received a notice of adverse benefit determination. For the
purposes of this Section, a Contractor provider site means
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any office or facility owned or operated by the Contractor or
a provider contracting with the Contractor at which
beneficiaries may obtain specialty mental health services.
(Cal. Code Regs., tit. 9, §§ 1850.205(c)(1)(B) and 1850.210.)
c) Make available forms that may be used to file grievances,
appeals, and expedited appeals and self-addressed
envelopes that beneficiaries can access at all Contractor
provider sites without having to make a verbal or written
request to anyone. (Cal. Code Regs., tit. 9, §
1850.205(c)(1)(C).)
d) Give beneficiaries any reasonable assistance in completing
the forms and other procedural steps related to a grievance
or appeal. This includes, but is not limited to, providing
interpreter services and toll-free numbers with TTY/TDD and
interpreter capability. (42 C.F.R. § 438.406(a); 42 C.F.R. §
438.228(a).)
2) The Contractor shall allow beneficiaries to file grievances and
request appeals. (42 C.F.R. § 438.402(c)(1).) The Contractor shall
have only one level of appeal for beneficiaries. (42 C.F.R. §
438.402(b); 42 C.F.R. § 438.228(a).)
3) A beneficiary may request a State fair hearing after receiving notice
under 438.408 that the adverse benefit determination is upheld. (42
C.F.R. § 438.402(c)(1); 42 C.F.R. § 438.408(f).)
4) The Contractor shall adhere to the notice and timing requirements
in §438.408. If the Contractor fails to adhere to these notice and
timing requirements, the beneficiary is deemed to have exhausted
the Contractor's appeals process and may initiate a State fair
hearing. (42 C.F.R. §§ 438.402(c)(1)(i)(A), 438.408(c)(3).)
5) The Contractor shall acknowledge receipt of each grievance,
appeal, and request for expedited appeal of adverse benefit
determinations to the beneficiary in writing. (42 C.F.R. §
438.406(b)(1); 42 C.F.R. § 438.228(a); Cal. Code Regs., tit. 9, §
1850.205(d)(4).) Grievances received over the telephone or in-
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Person by the Contractor, or a network provider of the
Contractor, that are resolved to the beneficiary's satisfaction
by the close of the next business day following receipt are
exempt from the requirement to send a written
acknowledgment.
6) The Contractor shall allow a provider, or authorized representative,
acting on behalf of the beneficiary and with the beneficiary's written
consent to request an appeal, file a grievance, or request a state
fair hearing. (42 C.F.R. § 438.402(c)(1)(i)-(ii); Cal. Code Regs., tit.
9, § 1850.205(c)(2).)
7) The Contractor shall allow a beneficiary's authorized representative
to use the grievance, appeal, or expedited appeal processes on the
beneficiary's behalf. (Cal. Code Regs., tit. 9, § 1850.205(c)(2).)
8) At the beneficiary's request, the Contractor shall identify staff or
another individual, such as a legal guardian, to be responsible for
assisting a beneficiary with these processes, including providing
assistance in writing the grievance, appeal, or expedited appeal. If
the individual identified by the Contractor is the person providing
specialty mental health services to the beneficiary requesting
assistance, the Contractor shall identify another individual to assist
that beneficiary. (Cal. Code Regs., tit. 9, § 1850.205(c)(4).)
Assistance includes, but is not limited to, auxiliary aids and services
upon request, such as providing interpreter services and toll-free
numbers with TTY/TDD and interpreter capability. (42 C.F.R. §
438.406(a).)
9) The Contractor shall not subject a beneficiary to discrimination or
any other penalty for filing a grievance, appeal, or expedited
appeal. (Cal. Code Regs., tit. 9, § 1850.205(c)(5).)
10) The Contractor's procedures for the beneficiary problem resolution
processes shall maintain the confidentiality of each beneficiary's
information. (Cal. Code Regs., tit. 9, § 1850.205(c)(6).)
11) The Contractor shall include a procedure to transmit issues
identified as a result of the grievance, appeal or expedited appeal
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processes to the Contractor's Quality Improvement Committee, the
Contractor's administration or another appropriate body within the
Contractor's operations. The Contractor shall consider these issues
in the Contractor's Quality Improvement Program, as required by
Cal. Code Regs., tit. 9, §1810.440(a)(5). (Cal. Code Regs., tit. 9, §
1850.205(c)(7).)
12) The Contractor shall ensure that decision makers on grievances
and appeals of adverse benefit determinations were not involved in
any previous level of review or decision-making, and were not
subordinates of any individual who was involved in a previous level
of review or decision-making. (42 C.F.R. § 438.406(b)(2)(i); 42
C.F.R. § 438.228(a).)
13) The Contractor shall ensure that individuals making decisions on
the grievances and appeals of adverse benefit determinations,
have the appropriate clinical expertise, as determined by the
Department , in treating the beneficiary's condition or disease, if the
decision involves an appeal based on a denial of medical necessity,
a grievance regarding denial of a request for an expedited appeal,
or if the grievance or appeal involves clinical issues.(42 C.F.R. §
438.406(b)(2)(ii)(A)-(C); 42 C.F.R. § 438.228(a).)
14) The Contractor shall provide the beneficiary a reasonable
opportunity, in person and in writing, to present evidence and
testimony and make legal and factual arguments. The Contractor
must inform the beneficiary of the limited time available for this
sufficiently in advance of the resolution timeframe for appeals
specified in §438.408(b) and (c) in the case of expedited resolution.
(42 C.F.R. § 438.406(b)(4).)
15) The Contractor shall ensure that decision makers on grievances
and appeals of adverse benefit determinations take into account all
comments, documents, records, and other information submitted by
the beneficiary or beneficiary's representative, without regard to
whether such information was submitted or considered in the initial
adverse benefit determination. (42 C.F.R. § 438.406(b)(2)(iii); 42
C.F.R. § 438.228(a).)
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16) The Contractor shall provide the beneficiary and his or her
representative the beneficiary's case file, including medical records,
other documents and records, and any new or additional evidence
considered, relied upon, or generated by the Contractor in
connection with the appeal of the adverse benefit determination.
(42 C.F.R. § 438.406(b)(5).)
17) The Contractor shall provide the beneficiary and his or her
representative the beneficiary's case file free of charge and
sufficiently in advance of the resolution timeframe for standard and
expedited appeal resolutions, (42 C.F.R. § 438.408(b)-(c).) For
standard resolution of an appeal and notice to the affected parties,
the Contractor must comply with the Department established
timeframe of 30 calendar days from the day the Contractor receives
the appeal. For expedited resolution of an appeal and notice to
affected parties, the Contractor must comply with the Department
established timeframe of 72 hours after the Contractor receives the
appeal. (42 C.F.R. § 438.406(b)(5).)
18) The Contractor shall treat oral inquiries seeking to appeal an
adverse benefit determination as appeals (to establish the earliest
possible filing date for the appeal) and must confirm these oral
inquiries in writing, unless the beneficiary or the provider requests
expedited resolution. (42 C.F.R. § 438.406(b)(3).)
19) The Contractor's beneficiary problem resolution process shall not
replace or conflict with the duties of county patient's rights
advocates. (Welf. & Inst. Code § 5520.)
2. Handling of Grievances and Appeals
The Contractor shall adhere to the following record keeping, monitoring, and
review requirements:
A. Maintain a grievance and appeal log and record grievances, appeals, and
expedited appeals in the log within one working day of the date of receipt
of the grievance, appeal, or expedited appeal. (42 C.F.R. § 438.416(a);
Cal. Code Regs., tit. 9, § 1850.205(d)(1).) Each record shall include, but
not be limited to: a general description of the reason for the appeal or
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grievance the date received, the date of each review or review meeting,
resolution information for each level of the appeal or grievance, if
applicable, and the date of resolution at each level, if applicable, and the
name of the covered person whom the appeal or grievance was filed. (42
C.F.R. § 438.416(b)(1)-(6).)
B. Record in the grievance and appeal log or another central location
determined by the Contractor, the final dispositions of grievances,
appeals, and expedited appeals, including the date the decision is sent to
the beneficiary. If there has not been final disposition of the grievance,
appeal, or expedited appeal, the reason(s) shall be included in the log.
(Cal. Code Regs., tit. 9, § 1850.205(d)(2).)
C. Provide a staff person or other individual with responsibility to provide
information requested by the beneficiary or the beneficiary's
representative regarding the status of the beneficiary's grievance, appeal,
or expedited appeal. (Cal. Code Regs., tit. 9, § 1850.205(d)(3).)
D. Identify in its grievance, appeal, and expedited appeal documentation, the
roles and responsibilities of the Contractor, the provider, and the
beneficiary. (Cal. Code Regs., tit. 9, § 1850.205(d)(5).)
E. Provide notice, in writing, to any provider identified by the beneficiary or
involved in the grievance, appeal, or expedited appeal of the final
disposition of the beneficiary's grievance, appeal, or expedited appeal.
(Cal. Code Regs., tit. 9, § 1850.205(d)(6).)
F. Maintain records in the grievance and appeal log accurately and in a
manner accessible to the Department and available upon request to CMS.
(42 C.F.R. § 438.416(c).)
3. Grievance Process
The Contractor's grievance process shall, at a minimum:
A. Allow beneficiaries to file a grievance either orally, or in writing at any time
with the Contractor; (42 C.F.R. § 438.402(c)(2)(i) and (c)(3)(i).)
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B. The Contractor shall provide to the beneficiary written
acknowledgement of receipt of the grievance. The acknowledgment
letter shall include the date of receipt, as well as the name, telephone
number, and address of the Plan representative who the beneficiary
may contact about the grievance. The written acknowledgement to
the beneficiary must be postmarked within five calendar days of
receipt of the grievance. Grievances received over the telephone or
in-person by the Contractor, or a network provider of the Contractor,
that are resolved to the beneficiary's satisfaction by the close of the
next business day following receipt are exempt from the requirement
to send a written notification of resolution using the Written
Notification of Grievance Resolution form.
C. Resolve each grievance as expeditiously as the beneficiary's health
condition requires not to exceed 90 calendar days from the day the
Contractor receives the grievance. (42 C.F.R. § 438.408(a)-(b)(1).) The
Contractor may extend the timeframe for processing a grievance by up to
14 calendar days if the beneficiary requests an extension, or if the
Contractor determines, to the satisfaction of DHCS upon request, that
there is a need for additional information and that the delay is in the
beneficiary's interest. (42 C.F.R. § 438.408(c)(1)(i)-(ii).) If the Contractor
extends the timeframe, the Contractor shall, for any extension not
requested by the beneficiary, make reasonable efforts to give the
beneficiary prompt oral notice of the delay and give the beneficiary written
notice of the extension and the reasons for the extension within 2 calendar
days of the decision to extend the timeframe. Contractor's written notice of
extension shall inform the beneficiary of the right to file a grievance if he or
she disagrees with the Contractor's decision (42 C.F.R. § 438.408(c)(2)(i)-
(ii).) The written notice of the extension is not a Notice of Adverse Benefit
Determination. (Cal. Code Regs., tit. 9, § 1810.230.5.)
D. The timeframe for resolving grievances related to disputes of a
Contractor's decision to extend the timeframe for making an
authorization decision shall not exceed 30 calendar days.
E. Provide written notification to the beneficiary or the appropriate
representative of the resolution of a grievance and documentation of the
notification or efforts to notify the beneficiary, if he or she could not be
contacted. (Cal. Code Regs.,tit. 9, § 1850.206(c).)
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F. Notify the beneficiary of the resolution of a grievance in a format and
language that meets applicable notification standards. (42 C.F.R. §
438.408(d)(1); 42 C.F.R. § 438.10.)
4. Discrimination Grievances
A. For Discrimination Grievances:
1) The Contractor shall designate a Discrimination Grievance
Coordinator who is responsible for ensuring compliance with
federal and state nondiscrimination requirements, and
investigating Discrimination Grievances related to any action
that would be prohibited by, or out of compliance with, federal
or state nondiscrimination law. (Welf. & Inst. Code §
14727(a)(4); 45 C.F.R. § 84.7; 34 C.F.R. § 106.8; 28 C.F.R.
35.107; see 42 U.S.C. § 18116(a); California's Medicaid State
Plan, Section 7, Attachments 7.2-A and 7.2-113.)
2) The Contractor shall adopt procedures to ensure the prompt
and equitable resolution of discrimination-related complaints.
(Welf. & Inst. Code § 14727(a)(4); 45 C.F.R. § 84.7; 34 C.F.R. §
106.8; 28 C.F.R. § 35.107; see 42 U.S.C. § 18116(a); California's
Medicaid State Plan, Section 7, Attachments 7.2-A and 7.2-B.)
The Contractor shall not require a beneficiary to file a
Discrimination Grievance with the Contractor before filing the
complaint directly with the DHCS Office of Civil Rights and the
U.S. Health and Human Services Office for Civil Rights.
3) Within ten calendar days of mailing a Discrimination Grievance
resolution letter to a beneficiary, the Contractor must submit
the following information regarding the complaint to the DHCS
Office of Civil Rights (see California Medicaid State Plan,
Section 7, Attachments 7.2-A and 7.2-113):
a) The original complaint.
b) The provider's or other accused party's response to the
complaint.
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c) Contact information for the personnel primarily
responsible for investigating and responding to the
complaint on behalf of the Contractor.
d) Contact information for the beneficiary filing the
complaint, and for the provider or other accused party
that is the subject of the complaint.
e) All correspondence with the beneficiary regarding the
complaint, including, but not limited to, the
Discrimination Grievance acknowledgment letter and
resolution letter sent to the beneficiary.
f) The results of the Contractor's investigation, copies of
any corrective action taken, and any other information
that is relevant to the allegation(s) of discrimination.
5. Appeals Process
A. The Contractor's appeal process shall, at a minimum:
1) Allow a beneficiary, or a provider or authorized representative
acting on the beneficiary's behalf, to file an appeal orally or in
writing. (42 C.F.R. § 438.402(c)(3)(ii).) The beneficiary may file an
appeal within 60 calendar days from the date on the adverse
benefit determination notice (42 C.F.R. § 438.402(c)(2)(ii).);
2) Require a beneficiary who makes an oral appeal that is not an
expedited appeal, to subsequently submit a written, signed appeal.
(42 C.F.R. § 438.402(c)(3)(ii).) The Contractor shall ensure that
oral inquiries seeking to appeal an adverse benefit determination
are treated as appeals, and confirmed in writing unless the
beneficiary or the provider requests expedited resolution. The date
the Contractor receives the oral appeal shall be considered the
filing date for the purpose of applying the appeal timeframes (42
C.F.R. § 438.406(b)(3).);
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3) Resolve each appeal and provide notice, as expeditiously as the
beneficiary's health condition requires, within 30 calendar days
from the day the Contractor receives the appeal. (42 C.F.R. §
438.408(a); 42 C.F.R. § 438.408(b)(2).) The Contractor may extend
the timeframe for processing an appeal by up to 14 calendar days,
if the beneficiary requests an extension or the Contractor
demonstratesdetermones, to the satisfaction of DHCS upon
request, that there is a need for additional information and that the
delay is in the beneficiary's interest. (42 C.F.R. 438.408(c)(1); 42
C.F.R. 438.408(b)(2).) If the Contractor extends the timeframes, the
Contractor shall, for any extension not requested by the beneficiary,
make reasonable efforts to give the beneficiary prompt oral notice
of the delay and notify the beneficiary of the extension and the
reasons for the extension in writing within 2 calendar days of the
decision to extend the timeframe. Contractor's written notice of
extension shall inform the beneficiary of the right to file a grievance
if he or she disagrees with the Contractor's decision. Contractor
shall resolve the appeal as expeditiously as the beneficiary's health
condition requires and no later than the date the extension expires
(42 C.F.R. § 438.408(c)(2)(i)-(iii).) The written notice of the
extension is not a Notice of Adverse Benefit Determination. (Cal.
Code Regs., tit. 9, §1810.230.5.);
4) Allow the beneficiary to have a reasonable opportunity to present
evidence and testimony and make arguments of fact or law, in
person and in writing (42 C.F.R. § 438.406(b)(4).);
5) Provide the beneficiary and his or her representative the
beneficiary's case file, including medical records, and any other
documents and records, and any new or additional evidence
considered, relied upon, or generated by the Contractor in
connection with the appeal of the adverse benefit determination ,
provided that there is no disclosure of the protected health
information of any individual other than the beneficiary (42 C.F.R. §
438.406(b)(5).); and
6) Provide the beneficiary and his or her representative the
beneficiary's case file free of charge and sufficiently in advance of
the resolution timeframe for standard appeal resolutions. For
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standard resolution of an appeal and notice to the affected parties,
the Contractor must comply with the Department established
timeframe of 30 calendar days from the day the Contractor receives
the appeal. For expedited resolution of an appeal and notice to
affected parties, the Contractor must comply with the Department
established timeframe of 72 hours after the Contractor receives the
appeal. (42 C.F.R. § 438.406(b)(5).)
7) Allow the beneficiary, his or her representative, or the legal
representative of a deceased beneficiary's estate, to be included as
parties to the appeal. (42 C.F.R. 438.406(b)(6).)
B. The Contractor shall notify the beneficiary, and/or his or her
representative, of the resolution of the appeal in writing in a format and
language that, at a minimum, meets applicable notification standards. (42
C.F.R. 438.408(d)(2)(i); 42 C.F.R. § 438.408(e); 42 C.F.R. 438.10.) The
notice shall contain the following:
1) The results of the appeal resolution process (42 C.F.R. §
438.408(e)(1).);
2) The date that the appeal decision was made (42 C.F.R. §
438.408(e)(1).);
3) If the appeal is not resolved wholly in favor of the beneficiary, the
notice shall also contain:
a) Information regarding the beneficiary's right to a fair hearing
and the procedure for requesting a fair hearing, if the
beneficiary has not already requested a fair hearing on the
issue involved in the appeal; (42 C.F.R. § 438.408(e)(2)(i).)
and
b) Information on the beneficiary's right to continue to receive
benefits while the fair hearing is pending and how to request
the continuation of benefits; (42 C.F.R. § 438.408(e)(2)(ii).)
c) Inform the beneficiary that he or she may be liable for the
cost of any continued benefits if the Contractor's adverse
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benefit determination is upheld in the hearing. (42 C.F.R. §
438.408(e)(2)(iii).)
6. Expedited Appeal Process
A. "Expedited Appeal" is an appeal used when the mental health plan
determines (for a request from the beneficiary) or the provider indicates (in
making the request on the beneficiary's behalf or supporting the
beneficiary's request) that taking the time for a standard resolution could
seriously jeopardize the beneficiary's life, physical or mental health, or
ability to attain, maintain, or regain maximum function. (42 C.F.R.
438.410.)
B. The Contractor's expedited appeal process shall, at a minimum:
1) Be used when the Contractor determines or the beneficiary and/or
the beneficiary's provider certifies that taking the time for a standard
appeal resolution could seriously jeopardize the beneficiary's life,
physical or mental health or ability to attain, maintain, or regain
maximum function. (42 C.F.R. 438.410(a).)
2) Allow the beneficiary to file the request for an expedited appeal
orally without requiring the beneficiary to submit a subsequent
written, signed appeal. (42 C.F.R. § 438.402(c)(3)(ii).)
3) Ensure that punitive action is not taken against a provider who
requests an expedited resolution or supports a beneficiary's
expedited appeal. (42 C.F.R. § 438.410(b).)
4) Inform beneficiaries of the limited time available to present
evidence and testimony, in person and in writing, and make legal
and factual arguments for an expedited appeal. The Contractor
must inform beneficiaries of this sufficiently in advance of the
resolution timeframe for the expedited appeal. (42 C.F.R.
438.406(b)(4); 42 C.F.R. 438.408(b)-(c).)
5) Resolve an expedited appeal and notify the affected parties in
writing, as expeditiously as the beneficiary's health condition
requires and no later than 72 hours after the Contractor receives
the appeal. (42 C.F.R. § 438.408(b)(3).) The Contractor may
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extend this timeframe by up to 14 calendar days if the beneficiary
requests an extension, or the Contractor demonstrates
determones, to the satisfaction of DHCS upon request, that there
is need for additional information and that the delay is in the
beneficiary's interest. (42 C.F.R. § 438.408(c)(1)(i)-(ii).) If the
Contractor extends the timeline for processing an expedited appeal
not at the request of the beneficiary, the Contractor shall make
reasonable efforts to give the beneficiary prompt oral notice of the
delay, and notify the beneficiary of the extension and the reasons
for the extension, in writing, within 2 calendar days of the
determination to extend the timeline. The Contractor shall resolve
the appeal as expeditiously as the beneficiary's health condition
requires and no later than the date the extension expires. (42
C.F.R. § 438.408(c)(2)(i) - (iii); 42 C.F.R. §438.408(b)(3).) The
written notice of the extension is not a Notice of Adverse Benefit
Determination. (Cal. Code Regs., tit. 9, § 1810.230.5.)
6) Provide a beneficiary with a written notice of the expedited appeal
disposition and make reasonable efforts to provide oral notice to
the beneficiary and/or his or her representative. The written notice
shall meet the requirements of Section 1850.207(h) of Title 9 of the
California Code of Regulations. (42 C.F.R. § 438.408(d)(2); Cal.
Code Regs., tit. 9, § 1850.207(h).)
7) If the Contractor denies a request for an expedited appeal
resolution, the Contractor shall:
a) Transfer the expedited appeal request to the timeframe for
standard resolution of no longer than 30 calendar days from
the day the Contractor receives the appeal. (42 C.F.R. §
438.410(c)(1).)
b) Make reasonable efforts to give the beneficiary and his or
her representative prompt oral notice of the denial of the
request for an expedited appeal. Provide written notice of the
decision and reason for the decision within two calendar
days of the date of the denial, and inform the beneficiary of
the right to file a grievance if he or she disagrees with the
decision. (42 C.F.R. § 438.410(c)(2); 42 C.F.R. §
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438.408(c)(2).) The written notice of the denial of the request
for an expedited appeal is not a Notice of Adverse Benefit
Determination. (Cal. Code Regs., tit. 9, § 1810.230.5.)
7. Contractor obligations related to State Fair Hearing
State "Fair Hearing" means the State hearing provided to beneficiaries pursuant
to sections 50951 and 50953 of Title 22 of the California Code of Regulations
sectien and section 1810.216.6 of Title 9 of the California Code of Regulations
1810.216.6.:
A. If a beneficiary requests a State Fair Hearing, the Department shall grant
the request. (42 C.F.R. § 431.220(a)(5).) The right to a State Fair Hearing,
how to obtain a hearing, and representation rules at a hearing must be
explained to the beneficiary and provider by Contractor in its notice of
decision or Notice of Adverse Benefit Determination. (42 C.F.R. §
431.206(b); 42 C.F.R. § 431.228(b).) Beneficiaries and providers shall
also be informed of the following:
1) A beneficiary may request a State Fair Hearing only after receiving
notice that the Contractor is upholding the adverse benefit
determination. (42 C.F.R. § 438.408(f)(1).)
2) If the Contractor fails to adhere to notice and timing requirements
under § 438.408, the beneficiary is deemed to have exhausted the
Contractor's appeals process, and the beneficiary may initiate a
state fair hearing. (42 C.F.R 438.408(f)(1)(i); 42 C.F.R.
438.402(c)(1)(i)(A).)
3) The provider may request a State Fair Hearing only if the
Department permits the provider to act as the beneficiary's
authorized representative. (42 C.F.R. § 438.402(c)(1)(ii).)
8. Expedited Fair Hearing
"Expedited Fair Hearing" means a fair hearing, used when the Contractor
determines, or the beneficiary or the beneficiary's provider certifies that following
the 90 day timeframe for a fair hearing as established in 42 C.F.R. §
431.244(f)(1) would seriously jeopardize the beneficiary's life, health, or ability to
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attain, maintain, or regain maximum function. (42 C.F.R. § 431.244(f)(1); 42
C.F.R. § 438.410(a); Cal. Code Regs., tit. 9, § 1810.216.4.)
9. Continuation of Services
A. A beneficiary receiving specialty mental health services shall have a right
to file for continuation of specialty mental health services pending the
outcome of a fair hearing. (Cal. Code Regs., tit. 22., § 51014.2; Cal. Code
Regs., tit. 9, § 1850.215.)
B. The Contractor shall continue the beneficiary's benefits while an appeal is
in process if all of the following occur:
1) The beneficiary files the request for an appeal within 60 calendar
days following the date on the adverse benefit determination notice;
(42 C.F.R. § 438.420(b)(1).)
2) The appeal involves the termination, suspension, or reduction of a
previously authorized service; (42 C.F.R. § 438.420(b)(2).)
3) The beneficiary's services were ordered by an authorized provider;
(42 C.F.R. § 438.420(b)(3).)
4) The period covered by the original authorization has not expired;
and, (42 C.F.R. § 438.420(b)(4).)
5) The request for continuation of benefits is filed on or before the
later of the following: (42 C.F.R. § 438.420 (b)(5).)
a. Within 10 calendar days of the Contractor sending the notice
of adverse benefit determination; (42 C.F.R. § 438.420(a).)
or
b. The intended effective date of the adverse benefit
determination. (42 C.F.R. § 438.420(a).)
C. If, at the beneficiary's request, the Contractor continues the beneficiary's
benefits while the appeal or state fair hearing is pending, the benefits must
be continued until the beneficiary withdraws the appeal or request for state
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fair hearing, the beneficiary does not request a state fair hearing and
continuation of benefits within 10 calendar days from the date the
Contractor sends the notice of an adverse appeal resolution, or a state fair
hearing decision adverse to the beneficiary is issued. (42 C.F.R. §
438.420(c)(1)-(3); 42 C.F.R. § 438.408(d)(2).)
D. The Contractor may recover the cost of continued services furnished to
the beneficiary while the appeal or state fair hearing was pending if the
final resolution of the appeal or state fair hearing upholds the Contractor's
adverse benefit determination. (42 C.F.R. § 438.420(d); 42 C.F.R. §
431.230(b).)
E. The Contractor shall authorize or provide the disputed services promptly,
and as expeditiously as the beneficiary's health condition requires, but no
later than 72 hours from the date the Contractor receives notice reversing
the determination if the services were not furnished while the appeal was
pending and if the Contractor or state fair hearing officer reverses a
decision to deny, limit, or delay services. (42 C.F.R. § 438.424(a).)
F. If the decision of an appeal reverses a decision to deny the authorization
of services, and the beneficiary received the disputed services while the
appeal was pending, the Contractor shall cover the cost of such services.
(42 C.F.R. § 438.424(b).)
G. The Contractor shall notify the requesting provider and give the
beneficiary written notice of any decision to deny a service authorization
request, or to authorize a service in an amount, duration, or scope that is
less than requested. (42 C.F.R. § 438.210(c); 42 C.F.R. § 438.404.)
10. Provision of Notice of Adverse Benefit Determination
A. The Contractor shall provide a beneficiary with a Notice of Adverse Benefit
Determination (NOABD) under the following circumstances:
1) The denial or limited authorization of a requested service, including
determinations based on the type or level of service, requirements
for medical necessity, appropriateness, setting, or effectiveness of
a covered benefit. (42 C.F.R. § 438.400(b)(1).)
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2) The reduction, suspension, or termination of a previously
authorized service. (42 C.F.R. § 438.400(b)(2).)
3) The denial, in whole or in part, of payment for a service. (42 C.F.R.
§ 438.400(b)(3).)
4) The failure to provide services in a timely manner, as defined by the
Department. (42 C.F.R. § 438.400(b)(4).)
5) The failure of the Contractor to act within the timeframes provided
in §438.408(b)(1) and (2) regarding the standard resolution of
grievances and appeals. (42 C.F.R. § 438.400(b)(5).)
6) The denial of a beneficiary's request to dispute a financial liability,
including cost sharing, copayments, premiums, deductibles,
coinsurance, and other beneficiary financial liabilities. (42 C.F.R. §
438.400(b)(7).)
B. The Contractor shall give beneficiaries timely and adequate notice of an
adverse benefit determination in writing and shall meet the language and
format requirements of 42 Code of Federal Regulations part 438.10. (42
C.F.R. § 438.404(a); 42 C.F.R. § 438.10.) The NOABD shall contain the
items specified in 42 Code of Federal Regulations part 438.404 (b) and
Cal.ofernma Code of RegulafieRs., tit.le 9, section 1850.212.
C. When the denial or modification involves a request from a provider for
continued Contractor payment authorization of a specialty mental health
service or when the Contractor reduces or terminates a previously
approved Contractor payment authorization, notice shall be provided in
accordance with Cal.+feria Code of Regulations., tit.le 22, section
51014.1. (Cal. Code Regs., tit. 9, § 1850.210(a)(1).)
D. A NOABD is not required when a denial is a non-binding verbal
description to a provider of the specialty mental health services that may
be approved by the Contractor. (Cal. Code Regs., tit. 9, § 1850.210(a)(2).)
E. Except as provided in subsection F below, a NOABD is not required when
the denial or modification is a denial or modification of a request for
Contractor payment authorization for a specialty mental health service that
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has already been provided to the beneficiary. (Cal. Code Regs., tit. 9, §
1850.210(a)(4).)
F. A NOABD is required when the Contractor denies or modifies a payment
authorization request from a provider for a specialty mental health service
that has already been provided to the beneficiary when the denial or
modification is a result of post-service, prepayment determination by the
Contractor that the service was not medically necessary or otherwise was
not a service covered by the Contractor. (Cal. Code Regs., tit. 9, §
1850.210(b).)
G. The Contractor shall deny the Contractor payment authorization request
and provide the beneficiary with a NOABD when the Contractor does not
have sufficient information to approve or modify, or deny on the merits, a
Contractor payment authorization request from a provider within the
timeframes required by Cal. Code Regs., tit. 9, §§ 1820.220 or 1830.215.
(Cal. Code Regs., tit. 9, § 1850.210(c).)
H. The Contractor shall provide the beneficiary with a NOABD if the
Contractor fails to notify the affected parties of a resolution of a grievance
within 90 calendar days, of an appeal decision within 30 days, or of an
expedited appeal decision within 72 hours. If the timeframe for a
grievance, appeal or expedited appeal decision is extended pursuant to
sections 1850.206, 1850.207 or 1850.208 of Title 9 of the California Code
of Regulations and the Contractor failed to notify the affected parties of its
decision within the extension period, the Contractor shall provide the
beneficiary with a NOABD. (42 C.F.R. § 438.408.)
I. The Contractor shall provide a beneficiary with a NOABD when the
Contractor or its providers determine that the medical necessity criteria in
sections 1830.205(b)(1),(b)(2),(b)(3)(C), or 1830.210(a) of Title 9 of the
California Code of Regulations have not been met and that the beneficiary
is not entitled to any specialty mental health services from the Contractor.
The NOABD shall, at the election of the Contractor, be hand-delivered to
the beneficiary on the date of the Adverse Benefit Determination or mailed
to the beneficiary in accordance with Cal. Code Regs., tit. 9, §
1850.210(f)(1), and shall specify the information contained in Cal. Code
Regs., tit. 9, § 1850.212(b). (Cal. Code Regs., tit. 9, § 1850.210(g).)
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J. For the purpose of this Attachment, each reference to a Medi-Cal
managed care plan in Cal. Code Regs., tit. 22, § 51014.1 , shall mean the
Contractor. (Cal. Code Regs., tit. 9, § 1850.210(h).)
K. For the purposes of this Attachment, "medical service", as used in Cal.
Code Regs., tit. 22, § 51014.1, shall mean specialty mental health
services that are subject to prior authorization by a Contractor pursuant to
Cal. Code Regs., tit. 9, §§ 1820.100 and 1830.100. (Cal. Code Regs., tit.
9, § 1850.210(i).)
L. The Contractor shall retain copies of all Notices of Adverse Benefit
Determination issued to beneficiaries under this Section in a centralized
file accessible to the Department. The Department shall engage in random
reviews (Cal. Code Regs., tit. 9, § 1850.210(j).)
M. The Contractor shall allow the State to engage in reviews of the
Contractor's records pertaining to Notices of Adverse Benefit
Determination so the Department may ensure that the Contractor is
notifying beneficiaries in a timely manner.
11. Contents and Timing of NOABD
A. The Contractor shall include the following information in the NOABD:
1) The adverse benefit determination the Contractor has made or
intends to make; (42 C.F.R. § 438.404(b)(1).)
2) The reason for the adverse benefit determination, including the right
of the beneficiary to be provided upon request and free of charge,
reasonable access to and copies of all documents, records, and
other information relevant to the beneficiary's adverse benefit
determination. Such information includes medical necessity criteria,
and any processes, strategies, or evidentiary standards used in
setting coverage limits; (42 C.F.R. § 438.404(b)(2).)
3) Citations to the regulations or Contractor payment authorization
procedures supporting the adverse benefit determination; (Cal.
Code Regs., tit. 9, § 1850.212(a)(3).)
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4) The beneficiary's right to file, and procedures for exercising, an
appeal or expedited appeal with the Contractor, including
information about exhausting the Contractor's one level of appeal
and the right to request a state fair hearing after receiving notice
that the adverse benefit determination is upheld; (42 C.F.R. §
438.404(b)(3)-(b)(4).)
5) The circumstances under which an appeal process can be
expedited and how to request it; (42 C.F.R. § 438.404(b)(5).)
6) The beneficiary's right to have benefits continue pending resolution
of the appeal, how to request that benefits be continued, and the
circumstances under which the beneficiary may be required to pay
the costs of those services. (42 C.F.R. § 438.404(b)(6).)
7) Information about the beneficiary's right to request a fair hearing or
an expedited fair hearing, including:
a) The method by which a hearing may be obtained; (Cal. Code
Regs., tit. 9, § 1850.212(a)(5)(A).)
b) A statement that the beneficiary may be either self-
represented, or represented by an authorized third party
such as legal counsel, a relative, friend, or any other person;
(Cal. Code Regs., tit. 9, § 1850.212(a)(5)(B).)
c) An explanation of the circumstances under which a specialty
mental health service will be continued if a fair hearing is
requested; (Cal. Code Regs., tit. 9, § 1850.212(a)(5)(C).)
and
d) The time limits for requesting a fair hearing or an expedited
fair hearing. (Cal. Code Regs., tit. 9, § 1850.212(a)(5)(D).)
B. The Contractor shall mail the NOABD within the following timeframes:
1) For termination, suspension, or reduction of previously authorized
Medi-Cal covered services, at least 10 days before the date of
action. (42 C.F.R. § 438.404(c)(1); 42 C.F.R. § 431.211 .) The
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Contractor shall mail the NOABD in as few as 5 days prior to the
date of action if the Contractor has facts indicating that action
should be taken because of probable fraud by the beneficiary, and
the facts have been verified, if possible, through secondary
sources. (42 C.F.R. § 438.404(c)(1); 42 C.F.R. §.431.214.)
2) For denial of payment, at the time of any action affecting the claim.
(42 C.F.R. § 438.404(c)(2).)
3) For standard service authorizations that deny or limit services, as
expeditiously as the beneficiary's condition requires not to exceed
14 calendar days following the receipt for request for services. (42
C.F.R. § 438.404(c)(3); 42 C.F.R. 438.210(d)(1).)
4) The Contractor may extend the 14 calendar day NOABD
determination timeframe for standard service authorization
decisions that deny or limit services up to 14 additional calendar
days if the beneficiary or the provider requests the extension. (42
C.F.R. § 438.404(c)(4); 42 C.F.R. 438.210(d)(1)(i).)
5) The Contractor may extend the 14 calendar day notice of adverse
benefit determination timeframe for standard service authorization
decisions that deny or limit services up to 14 additional calendar
days if the Contractor justifies a need to the Department, upon
request, for additional information and shows how the extension is
in the beneficiary's best interest. (42 C.F.R. § 438.404(c)(4); 42
C.F.R. 438.210(d)(1)(ii).)
6) If the Contractor extends the 14 calendar day notice of adverse
benefit determination timeframe for standard service authorization
decisions that deny or limit services, the Contractor shall do the
following:
a) Give the beneficiary written notice of the reason for the
extension and inform the beneficiary of the right to file a
grievance if he/she disagrees with the decision ; (42 C.F.R. §
438.404(c)(4)(i); 42 C.F.R. 438.210(d)(1)(ii).) and,
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b) Issue and carry out its determination as expeditiously as the
beneficiary's health condition requires and no later than the
date of the extension. (42 C.F.R. § 438.404(c)(4)(ii); 42
C.F.R. 438.210(d)(1)(ii).)
7) The Contractor shall give notice on the date that the timeframes
expire, when service authorization decisions are not reached within
the applicable timeframes for either standard or expedited service
authorizations. (42 C.F.R. § 438.404(c)(5).)
8) If a provider indicates, or the Contractor determines, that following
the standard service authorization timeframe could seriously
jeopardize the beneficiary's life or health or his or her ability to
attain, maintain, or regain maximum function, the Contractor must
make an expedited service authorization decision and provide
notice as expeditiously as the beneficiary's health condition
requires and no later than 72 hours after receipt of the request for
service. (42 C.F.R. § 438.404(c)(6); 42 C.F.R. 438.210(d)(2)(i).)
9) The Contractor may extend the 72 hour expedited service
authorization decision time period by up to 14 calendar days if the
beneficiary requests an extension, or if the Contractor justifies to
the Department, upon request, a need for additional information
and how the extension is in the beneficiary's interest. (42 C.F.R. §
438.404(c)(6); 42 C.F.R. § 210(d)(2)(ii).)
10) The Contractor shall deposit the NOABD with the United States
Postal Service in time for pick-up on the date that the applicable
timeframe expires. (Cal. Code Regs., tit. 9, § 1850.210(f).)
C. The Adverse Benefit Determination shall be effective on the date of the
NOABD and the Contractor shall mail the NOABD by the date of adverse
benefit determination when any of the following occur-
1) The death of a beneficiary; (42 C.F.R. § 431.213(a).)
2) Receipt of a signed written beneficiary statement requesting service
termination or giving information requiring termination or reduction
of services, provided the beneficiary understands that this will be
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the result of supplying that information; (42 C.F.R. § 431.213(b)(1)-
(b)(2).)
3) The beneficiary's admission to an institution where he or she is
ineligible for further services; (42 C.F.R. § 431.213(c).)
4) The beneficiary's whereabouts are unknown and mail directed to
him or her has no forwarding address; (42 C.F.R. § 431.213(d).)
5) Notice that the beneficiary has been accepted for Medicaid services
by another local jurisdiction; (42 C.F.R. § 431.213(e).)
6) A change in the beneficiary's physician's prescription for the level of
medical care; (42 C.F.R. § 431.213(f).) or
7) The notice involves an adverse determination with regard to
preadmission screening requirements of section 1919(e)(7) of the
Act. (42 C.F.R. § 431.213(g).)
8) The transfer or discharge from a facility will occur in an expedited
fashion. (42 C.F.R. § 431.213(h).)
9) Endangerment of the safety or health of individuals in the facility;
improvement in the resident's health sufficient to allow a more
immediate transfer or discharge; urgent medical needs that require
a resident's immediate transfer or discharge; or notice that a
resident has not resided in the nursing facility for 30 days (but only
in Adverse Benefit Determinations based on NF transfers).
12. Annual Grievance and Appeal Report
The Contractor is required to submit to the Department a report that summarizes
beneficiary grievances, appeals and expedited appeals filed from July 1 of the
previous year through June 30 of that year by October 1 of each year. The report
shall include the total number of grievances, appeals and expedited appeals by
type, by subject areas established by the Department, and by disposition. (Cal.
Code Regs., tit. 9, § 1810.375(a).)
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1. General Requirements
As a condition for receiving payment under a Medi-Cal managed care program,
the Contractor shall comply with the provisions of 42 C.F.R. §§ 438.604, 438.606
and 438.608, and 438.610. (42 C.F.R. § 438.600(b).)
2. Excluded Providers
A. The Contractor shall screen and periodically revalidate all network
providers in accordance with the requirements of 42 Code of Federal
Regulations, part 455, subparts B and E. (42 C.F.R. §438.602(b).)
B. Consistent with the requirements of 42 Code of Federal Regulations, part
455.436, the Contractor must confirm the identity and determine the
exclusion status of all providers (employees and network providers) and
any subcontractor, as well as any person with an ownership or control
interest, or who is an agent or managing employee of the of the Mental
Health Plan through routine checks of Federal and State databases. This
includes the Social Security Administration's Death Master File, the
National Plan and Provider Enumeration System (NPPES), the Office of
Inspector General's List of Excluded Individuals/Entities (LEIE), the
System for Award Management (SAM), as well as the Department's Medi
Cal Suspended and Ineligible Provider List (S & I List). (42 C.F.R.
§438.602(d).)
C. If the Contractor find a party that is excluded, it must promptly notify the
Department (42 C.F.R. §438.608(a)(2),(4)) and the Department will take
action consistent with 42 C.F.R. §438.610((d). The Contractor shall not
certify or pay any excluded provider with Medi-Cal funds, and any such
inappropriate payments or overpayments may be subject to recovery
and/or be the basis for other sanctions by the appropriate authority.
3. Compliance Program
A. Pursuant to 42 C.F.R. § 455.1(a)(1), the Contractor must report fraud and
abuse information to the Department.
B. The Contractor, or any subcontractor, to the extent that the subcontractor
is delegated responsibility by the Contractor for coverage of services and
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payment of claims under this Contract, shall implement and maintain a
compliance program designed to detect and prevent fraud, waste and
abuse that must include:
1) Written policies, procedures, and standards of conduct that
articulate the organization's commitment to comply with all
applicable requirements and standards under the contract, and all
applicable Federal and state requirements.
2) A Compliance Officer (CO) who is responsible for developing and
implementing policies, procedures, and practices designed to
ensure compliance with the requirements of the contract and who
reports directly to the CEO and the Board of Directors (BoD).
3) A Regulatory Compliance Committee (RCC) on the BoD and at the
senior management level charged with overseeing the
organization's compliance program and its compliance with the
requirements under the contract.
4) A system for training and education for the CO, the organization's
senior management, and the organization's employees for the
federal and state standards and requirements under the contract.
5) Effective lines of communication between the CO and the
organization's employees.
6) Enforcement of standards through well-publicized disciplinary
guidelines.
7) The establishment and implementation of procedures and a system
with dedicated staff for routine internal monitoring and auditing of
compliance risks, prompt response to compliance issues as they
are raised, investigation of potential compliance problems as
identified in the course of self-evaluation and audits, correction of
such problems promptly and thoroughly (or coordination of
suspected criminal acts with law enforcement agencies) to reduce
the potential for recurrence, and ongoing compliance with the
requirements under the contract. (42 C.F.R. §438.608(a), (a)(1).)
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4. Fraud Reporting Requirements
A. The Contractor, or any subcontractor, to the extent that the subcontractor
is delegated responsibility by the Contractor for coverage of services and
payment of claims under this Contract, shall implement and maintain
arrangements or procedures designed to detect and prevent fraud, waste
and abuse that include prompt reporting to the Department about the
following:
1) Any potential fraud, waste, or abuse. (42 C.F.R. §438.608(a),
(a)(7).)
2) All overpayments identified or recovered, specifying the
overpayments due to potential fraud. (42 C.F.R. §438.608(a),
(a)(2).)
3) Information about changes in a beneficiary's circumstances that
may affect the beneficiary's eligibility including changes in the
beneficiary's residence or the death of the beneficiary. (42 C.F.R.
§438.608(a), (a)(3).)
4) Information about a change in a network provider's circumstances
that may affect the network provider's eligibility to participate in the
managed care program, including the termination of the provider
agreement with the Contractor. (42 C.F.R. §438.608(a), (a)(4).)
B. If the Contractor identifies an issue or receives notification of a complaint
concerning an incident of potential fraud, waste or abuse, in addition to
notifying the Department, the Contractor shall conduct an internal
investigation to determine the validity of the issue/complaint, and develop
and implement corrective action, if needed.
C. The Contractor shall implement and maintain written policies for all
employees of the Mental Health Plan, and of any contractor or agent, that
provide detailed information about the False Claims Act and other Federal
and state laws, including information about rights of employees to be
protected as whistleblowers. (42 C.F.R. §438.608(a), (a)(6).)
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D. The Contractor shall implement and maintain arrangements or procedures
that include provision for the Contractor's suspension of payments to a
network provider for which there is a credible allegation of fraud. (42
C.F.R. §438.608(a), (a)(8).)
5. Service Verification
Pursuant to 42 C.F.R. § 438.608(a)(5), the Contractor, and/or any subcontractor,
to the extent that the subcontractor is delegated responsibility by the Contractor
for coverage of services and payment of claims under this Contract, shall
implement and maintain arrangements or procedures designed to detect and
prevent fraud, waste and abuse that include provisions to verify, by sampling or
other methods, whether services that have been represented to have been
delivered by network providers were received by beneficiaries and the application
of such verification processes on a regular basis. (42 C.F.R. §438.608(a),
(a)(5).)
6. Disclosures
A. Disclosure of 5% or More Ownership Interest:
1) Pursuant to 42 C.F.R. § 455.104, Medicaid managed care entities
must disclose certain information related to persons who have an
ownership or control interest in the managed care entity, as defined
in 42 C.F.R. § 455.101. The parties hereby acknowledge that
because the Contractor is a political subdivision of the State of
California, there are no persons who meet such definition and
therefore there is no information to disclose.
a) In the event that, in the future, any person obtains an interest
of 5% or more of any mortgage, deed of trust, note or other
obligation secured by Contractor, and that interest equals at
least 5% of Contractor's property or assets, then the
Contractor will make the disclosures set forth in i and
subsection 2(a).
i. The Contractor will disclose the name, address, date
of birth, and Social Security Number of any managing
employee, as that term is defined in 42 C.F.R. §
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455.101. For purposes of this disclosure, Contractor
may use the business address for any member of its
Board of Supervisors.
ii. The Contractor shall provide any such disclosure
upon execution of this contract, upon its extension or
renewal, and within 35 days after any change in
Contractor ownership or upon request of the
Department.
2) The Contractor shall ensure that its subcontractors and network
providers submit the disclosures below to the Contractor regarding
the network providers' (disclosing entities') ownership and control.
The Contractor's network providers must be required to submit
updated disclosures to the Contractor upon submitting the provider
application, before entering into or renewing the network providers'
contracts, within 35 days after any change in the
subcontractor/network provider's ownership, annually and upon
request during the re-validation of enrollment process under 42
Code of Federal Regulations part 455.104.
a) Disclosures to be Provided:
i. The name and address of any person (individual or
corporation) with an ownership or control interest in
the network provider. The address for corporate
entities shall include, as applicable, a primary
business address, every business location, and a
P.O. Box address;
ii. Date of birth and Social Security Number (in the case
of an individual);
iii. Other tax identification number (in the case of a
corporation with an ownership or control interest in
the managed care entity or in any subcontractor in
which the managed care entity has a 5 percent or
more interest);
iv. Whether the person (individual or corporation) with an
ownership or control interest in the Contractor's
network provider is related to another person with
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PROGRAM INTEGRITY
ownership or control interest in the same or any other
network provider of the Contractor as a spouse,
parent, child, or sibling; or whether the person
(individual or corporation) with an ownership or
control interest in any subcontractor in which the
managed care entity has a 5 percent or more interest
is related to another person with ownership or control
interest in the managed care entity as a spouse,
parent, child, or sibling;
V. The name of any other disclosing entity in which the
Contractor or subcontracting network provider has an
ownership or control interest; and
vi. The name, address, date of birth, and Social Security
Number of any managing employee of the managed
care entity.
3) For each provider in Contractor's provider network, Contractor shall
provide the Department with all disclosures before entering into a
network provider contract with the provider and annually thereafter
and upon request from the Department during the re-validation of
enrollment process under 42 Code of Federal Regulations part
455.104.
B. Disclosures Related to Business Transactions — Contractor must submit
disclosures and updated disclosures to the Department or HHS including
information regarding certain business transactions within 35 days, upon
request.
1) The following information must be disclosed:
a) The ownership of any subcontractor with whom the
Contractor has had business transactions totaling more than
$25,000 during the 12-month period ending on the date of
the request; and
b) Any significant business transactions between the
Contractor and any wholly owned supplier, or between the
Contractor and any subcontractor, during the 5-year period
ending on the date of the request.
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Exhibit A—Attachment 13 Al
PROGRAM INTEGRITY
c) Contractor must obligate Network Providers to submit the
same disclosures regarding network providers as noted
under subsection 1(a) and (b) within 35 days upon request.
C. Disclosures Related to Persons Convicted of Crimes
1) Contractor shall submit the following disclosures to the Department
regarding the Contractor's management:
a) The identity of any person who is a managing employee of
the Contractor who has been convicted of a crime related to
federal health care programs. (42 C.F.R. § 455.106(a)(1),
(2).)
b) The identity of any person who is an agent of the Contractor
who has been convicted of a crime related to federal health
care programs. (42 C.F.R. § 455.106(a)(1), (2).) For this
purpose, the word "agent" has the meaning described in 42
Code of Federal Regulations part 455.101.
2) The Contractor shall supply the disclosures before entering into the
contract and at any time upon the Department's request.
3) Network providers should submit the same disclosures to the
Contractor regarding the network providers' owners, persons with
controlling interest, agents, and managing employees' criminal
convictions. Network providers shall supply the disclosures before
entering into the contract and at any time upon the Department's
request.
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Exhibit A—Attachment 14 Al
REPORTING REQUIREMENTS
1. Data Submission/ Certification Requirements
A. The Contractor shall submit any data, documentation, or information
relating to the performance of the entity's obligations as required by the
State or the United States Secretary of Health and Human Services. (42
C.F.R. § 438.604(b).) The individual who submits this data to the state
shall concurrently provide a certification, which attests, based on best
information, knowledge and belief that the data, documentation and
information is accurate, complete and truthful. (42 C.F.R. § 438.606(b)
and (c).)The data, documentation, or information submitted to the state by
the Contractor shall be certified by one of the following:
1) The Contractor's Chief Executive Officer (CEO).
2) The Contractor's Chief Financial Officer (CFO).
3) An individual who reports directly to the CEO or CFO with
delegated authority to sign for the CEO or CFO so that the CEO or
CFO is ultimately responsible for the certification. (42 C.F. R. §
438.606(a).)
2. Encounter Data
The Contractor shall submit encounter data to the Department at a frequency
and level specified by the Department and CMS. (42 C.F.R. § 438.242(c)(2).)
The Contractor shall ensure collection and maintenance of sufficient beneficiary
encounter data to identify the provider who delivers service(s) to the beneficiary.
(42 C.F.R. § 438.242(c)(1).) The Contractor shall submit all beneficiary encounter
data that the Department is required to report to CMS under § 438.818. (42
C.F.R. § 438.242(c)(3).) The Contractor shall submit encounter data to the state
in standardized Accredited Standards Committee (ASC) X12N 837 and National
Council for Prescription Drug Programs (NCPDP) formats, and the ASC X12N
835 format as appropriate. (42 C.F.R. § 438.242(c)(4).)
3. Insolvency
A. The Contractor shall submit data to demonstrate it has made adequate
provision against the risk of insolvency to ensure that beneficiaries will not
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Exhibit A—Attachment 14 Al
REPORTING REQUIREMENTS
be liable for the Contractor's debt if the Contractor becomes insolvent. (42
C.F.R. § 438.604(a)(4); 42 C.F.R. § 438.116.)
B. The Contractor shall meet the State's solvency standards for private
health maintenance organizations or be licensed by the State as a risk-
bearing entity, unless one of the following exceptions apply (42 C.F.R. §
438.116 (b).):
1) The Contractor does not provide both inpatient hospital services
and physician services.
2) The Contractor is a public entity.
3) The Contractor is (or is controlled by) one of more federally
qualified health centers and meets the solvency standards
established by the State for those centers.
4) The Contractor has its solvency guaranteed by the State.
4. Network Adequacy
The Contractor shall submit, in a manner and format determined by the
Department, documentation to demonstrate compliance with the Department's
requirements for availability and accessibility of services, including the adequacy
of the provider network. (42 C.F.R. § 438.604(a)(5).)
5. Information on Ownership and Control
The Contractor shall submit for state review information on its and its
subcontractors' ownership and control described in 42 C.F.R. §455.104 and
Attachment 13 of this Contract. (42 C.F.R § 438.604(a)(6).)
6. Annual Report of Overpayment Recoveries
The Contractor shall submit an annual report of overpayment recoveries in a
manner and format determined by the Department. (42 C.F.R § 438.604(a)(7).)
7. Performance Data
A. In an effort to improve the performance of the State's managed care
program, in accordance with 42 Code of Federal Regulations part
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Exhibit A—Attachment 14 Al
REPORTING REQUIREMENTS
438.66(c), the Contractor will submit the following to the Department (42
C.F.R. §438.604(b).):
1) Enrollment and disenrollment data;
2) Member grievance and appeal logs;
3) Provider complaint and appeal logs;
4) The results of any beneficiary satisfaction survey;
5) The results of any provider satisfaction survey;
6) Performance on required quality measures;
7) Medical management committee reports and minutes;
8) The Contractor's annual quality improvement plan;
9) Audited financial and encounter data; and
10) Customer service performance data.
8. Parity in Mental Health and Substance Use Disorder Services
The Contractor shall submit to the Department, upon request, any policies
and procedures or other documentation necessary for the State to
establish and demonstrate compliance with Title 42 of the Code of Federal
Regulations, part 438, subpart K, regarding parity in mental health and
substance use disorder benefits.
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Exhibit B Al
BUDGET DETAIL AND PAYMENT PROVISIONS
1. Payment Provisions
This program may be funded using one or more of the following funding sources: funds
distributed to the counties from the Mental Health Subaccount, the Mental Health Equity
Subaccount, and the Vehicle License Collection Account of the Local Revenue Fund,
funds from the Mental Health Account and the Behavioral Health Subaccount of the Local
Revenue Fund 2011, funds from the Mental Health Services Fund, and any other funds
from which the Controller makes distributions to the counties in compliance with
applicable statute and regulations including Welf. & Inst. Code §§ 5891, 5892 and
14705(a)(2). These funding sources may be used by the Contractor to pay for services
and then certify as public expenditures in order to be reimbursed federal funds.
2. Budget Contingency Clause
This provision is a supplement to provision number nine (Federal Contract Funds) in
Exhibit D(F) which is attached hereto as part of this Contract.
A. Federal Budget
If federal funding for FFP reimbursement in relation to this contract is eliminated or
substantially reduced by Congress, the Department and the Contractor each shall
have the option either to cancel this contract or to propose a contract amendment
to address changes to the program required as a result of the elimination or
reduction of federal funding.
B. Delayed Federal Funding
Contractor and Department agree to consult with each other on interim measures
for program operation that may be required to maintain adequate services to
beneficiaries in the event that there is likely to be a delay in the availability of
federal funding.
3. Federal Financial Participation
Nothing in this contract shall limit the Contractor's ability to submit claims for appropriate
FFP reimbursement based on actual, total fund expenditures for any covered services or
quality assurance, utilization review, Medi-Cal Administrative Activities and/or
administrative costs. In accordance the Welf. & Inst. Code § 14705(c), the Contractor
shall ensure compliance with all requirements necessary for Medi-Cal reimbursement for
these services and activities. Claims for FFP reimbursement shall be submitted by the
Contractor to the Department for adjudication throughout the fiscal year. Pursuant to the
Welf. & Inst. Code § 14705(d), the Contractor shall certify to the state that it has incurred
public expenditures prior to requesting the reimbursement of federal funds.
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Exhibit B Al
BUDGET DETAIL AND PAYMENT PROVISIONS
4. Audits and Recovery of Overpayments
A. Pursuant to Welf. & Inst. Code § 14707, in the case of federal audit exceptions, the
Department will follow federal audit appeal processes unless the Department, in
consultation with the California Mental Health Director's Association, determines
that those appeals are not cost beneficial.
1) Whenever there is a final federal audit exception against the State resulting
from a claim for federal funds for an expenditure by individual counties that
is not federally allowable, the department may offset federal reimbursement
and request the Controller's office to offset the distribution of funds to the
Contractor from the Mental Health Subaccount, the Mental Health Equity
Subaccount and the Vehicle License Collection Account of the Local
Revenue Fund; funds from the Mental Health Account and the Behavioral
Health Subaccount of the Local Revenue Fund 2011; and any other mental
health realignment funds from which the Controller makes distributions to
the counties by the amount of the exception. The Department shall provide
evidence to the Controller that the county had been notified of the amount of
the audit exception no less than 30 days before the offset is to occur.
2) The Department will involve the Contractor in developing responses to any
draft federal audit reports that directly impact the county.
B. Pursuant to Welf. & Inst. Code § 14718(b)(2), the Department may offset the
amount of any federal disallowance, audit exception, or overpayment against
subsequent claims from the Contractor.
1) The Department may offset the amount of any state disallowance, audit
exception, or overpayment for fiscal years through and including 2010-11
against subsequent claims from the Contractor.
2) Offsets may be done at any time, after the department has invoiced or
otherwise notified the Contractor about the audit exception, disallowance, or
overpayment. The Department shall determine the amount that may be
withheld from each payment to the mental health plan.
3) The maximum withheld amount shall be 25 percent of each payment as
long as the Department is able to comply with the federal requirements for
repayment of FFP pursuant 42 United States Code (U.S.C.) §1396b(d)(2)).
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Exhibit B Al
BUDGET DETAIL AND PAYMENT PROVISIONS
The Department may increase the maximum amount when necessary for
compliance with federal laws and regulations.
C. Pursuant to the Welf. & Inst. Code § 14170, cost reports submitted to the
Department are subject to audit in the manner and form prescribed by the
Department. The year-end cost report shall include both Contractor's costs and
the costs of its subcontractors, if any. Contractor and its subcontractors shall be
subject to audits and/or reviews, including client record reviews, by the
Department. In accordance with the Welf. & Inst. Code § 14170, any audit of
Contractor's cost report shall occur within three years of the date of receipt by the
Department of the final cost report with signed certification by the Contractor's
Mental Health Director and one of the following: (1) the Contractor's Chief
Financial Officer (or equivalent), (2) an individual who has delegated authority to
sign for, and reports directly to the Contractor's Chief Financial Officer, or (3) the
county auditor controller, or equivalent. Both signatures are required before the
cost report shall be considered final. For purposes of this section, the cost report
shall be considered audited once the Department has informed the Contractor of
its intent to disallow costs on the cost report, or once the Department has informed
the Contractor of its intent to close the audit without disallowances.
D. If the adjustments result in the Department owing FFP to the Contractor, the
Department shall submit a claim to the federal government for the related FFP
within 30 days contingent upon sufficient budget authority.
5. Claims Adjudication Process
A. In accordance with the Welf. & Inst. Code §14705(c), claims for federal funds in
reimbursement for services shall comply with eligibility and service requirements
under applicable federal and state law.
B. The Contractor shall certify each claim submitted to the Department in accordance
with Cal. Code Regs., tit. 9, § 1840.112 and 42 C.F.R. § 433.51, at the time the
claims are submitted to the Department. The Contractor's Chief Financial Officer
or his or her equivalent, or an individual with authority delegated by the county
auditor-controller, shall sign the certification, declaring, under penalty of perjury,
that the Contractor has incurred an expenditure to cover the services included in
the claims to satisfy the requirements for FFP. The Contractor's Mental Health
Director or an individual with authority delegated by the Mental Health Director
shall sign the certification, declaring, under penalty of perjury that, to the best of his
or her knowledge and belief, the claim is in all respects true, correct, and in
accordance with the law and meets the requirements of Cal. Code Regs., tit. 9, §
1840.112(b). The Contractor shall have mechanisms that support the Mental
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Exhibit B Al
BUDGET DETAIL AND PAYMENT PROVISIONS
Health Director's certification, including the certification that the services for which
claims were submitted were actually provided to the beneficiary. If the Department
requires additional information from the Contractor that will be used to establish
Department payments to the Contractor, the Contractor shall certify that the
additional information provided is in accordance with 42 C.F.R. § 438.604.
C. Claims not meeting federal and/or state requirements shall be returned to
Contractor as not approved for payment, along with a reason for denial. Claims
meeting all Health Insurance Portability and Accountability Act (HIPAA) transaction
requirements and any other applicable federal or state privacy laws or regulations
and certified by the Contractor in accordance with Cal. Code Regs., tit. 9,
§1840.112, shall be processed for adjudication.
D. Good cause justification for late claim submission is governed by applicable federal
and state laws and regulations and is subject to approval by the Department.
E. In the event that the Department or the Contractor determines that changes
requiring a change in the Contractor's or Department's obligation must be made
relating to either the Department's or the Contractor's claims submission and
adjudication systems due to federal or state law changes or business
requirements, both the Department and the Contractor agree to provide notice to
the other party as soon as practicable prior to implementation. This notice shall
include information and comments regarding the anticipated requirements and
impacts of the projected changes. The Department and the Contractor agree to
meet and discuss the design, development, and costs of the anticipated changes
prior to implementation.
F. The Contractor shall comply with Cal. Code Regs., tit. 9, § 1840.304, when
submitting claims for FFP for services billed by individual or group providers. The
Contractor shall submit service codes from the Health Care Procedure Coding
System (HCPCS) published in the most current Mental Health Medi-Cal billing
manual.
6. Payment Data Certification
Contractor shall certify the data it provides to the Department to be used in determining
payment of FFP to the Contractor, in accordance with 42 C.F.R. §§ 438.604 and 438.606.
7. System Changes
In the event changes in federal or state law or regulations, including court decisions and
interpretations, necessitate a change in either the fiscal or program obligations or
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Exhibit B Al
BUDGET DETAIL AND PAYMENT PROVISIONS
operations of the Contractor or the Department, or a change in obligation for the cost of
providing covered services the Department and the Contractor agree to negotiate,
pursuant to the Welf. & Inst. Code § 14714(c) regarding (a) changes required to remain in
compliance with the new law or changes in existing obligations, (b) projected
programmatic and fiscal impacts, (c) necessary contract amendments. To the extent that
contract amendments are necessary, the parties agree to act to ensure appropriate
amendments are made to accommodate any changes required by law or regulation.
8. Administrative Reimbursement
A. The Contractor may submit claims for reimbursement of Medical Administrative
Activities (MAA) pursuant to Welf. & Inst. Code § 14132.47. The Contractor shall
not submit claims for MAA unless it has submitted a claiming plan to the
Department which was approved by the Department and is effective during the
quarter in which the costs being claimed were incurred. In addition, the Contractor
shall not submit claims for reimbursements of MAA that are not consistent with the
Contractor's approved MAA claiming plan. The Contractor shall not use the relative
value methodology to report its MAA costs on the year-end cost report. Rather,
the Contractor shall calculate and report MAA units on the cost report by
multiplying the amount of time (minutes, hours, etc.) spent on MAA activities by the
salary plus benefits of the staff performing the activity and then allocating indirect
administrative and other appropriately allocated costs.
B. Pursuant to the Welf. & Inst. Code § 14711(c), administrative costs shall be
claimed separately in a manner consistent with federal Medicaid requirements and
the approved Medicaid state plans and waivers and shall be limited to 15 percent
of the total actual cost of direct client services. The cost of performing quality
assurance and utilization review activities shall be reimbursed separately and shall
not be included in administrative costs.
9. Notification of Request for Contract Amendment
In addition to the provisions in Exhibit E, Additional Provisions, both parties agree to notify
the other party whenever an amendment to this contract is to be requested so that
informal discussion and consultation can occur prior to a formal amendment process.
County of Fresno
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Exhibit E Al
ADDITIONAL PROVISIONS
1. Additional Incorporated Exhibits
A. The following additional exhibits are attached, incorporated herein, and made a part
hereof by this reference:
1) Exhibit A, Documentation Requirements 7 page(s)
Attachment 9
2) Exhibit A, Coordination And Continuity Of Care 2 page(s)
Attachment 10
3) Exhibit A, Information Requirements 13 pages
Attachment 11
4) Exhibit A, Beneficiary Problem Resolution 23 pages
Attachment 12
5) Exhibit A, Program Integrity 7 pages
Attachment 13
6) Exhibit A, Reporting Requirements 3 pages
Attachment 14
7) Exhibit B Budget Detail And Payment Provisions 5 pages
8) Exhibit C * General Terms And Conditions GTC 04/2017
9) Exhibit D (F) Special Terms And Conditions (Attached 27 pages
hereto as part of this agreement)
(Notwithstanding Provisions 2, 3, 4, 6 ,8,
12, 14, 22, 25, 29, and 30 which do not
apply to this agreement.)
10)Exhibit E Additional Provisions (Program Terms And 17 pages
Conditions)
11)Exhibit E, Definitions 5 pages
Attachment 1
12)Exhibit E, Service Definitions 6 pages
Attachment 2
13)Exhibit F HIPAA Business Associate Addendum 27 pages
14)Exhibit F, Information Security Exchange Agreement 101 pages
Attachment B between the Social Security Administration
(SSA) and the California Department of
Health Care Services (DHCS)
2. Amendment Process
Should either party, during the term of this Contract, desire a change or
amendment to the terms of this Contract, such changes or amendments shall be
proposed in writing to the other party, who will respond in writing as to whether
County of Fresno
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Exhibit E Al
ADDITIONAL PROVISIONS
the proposed changes/amendments are accepted or rejected. If accepted and
after negotiations are concluded, the agreed upon changes shall be made
through the State's official agreement amendment process. No amendment will
be considered binding on either party until it is formally approved by both parties
and the Department of General Services (DGS), if DGS approval is required.
3. Cancellation/Termination
A. General Provisions
1) As required by, if the Contractor decides not to contract with the
Department, does not renew its contract, or is unable to meet the
standards set by the Department, the Contractor agrees to inform
the Department of this decision in writing. (Welf. & Inst. Code §
14712(c)(1).)
2) If the Contractor is unwilling to contract for the delivery of specialty
mental health services or if the Department or Contractor
determines that the Contractor is unable to adequately provide
specialty mental health services or that the Contractor does not
meet the standards the Department deems necessary for a mental
health plan, the Department shall ensure that specialty mental
health services are provided to Medi-Cal beneficiaries. (Welf. &
Inst. Code § 147122(c)(2), (3).)
3) The Department may contract with qualifying individual counties,
counties acting jointly, or other qualified entities approved by the
Department for the delivery of specialty mental health services in
any county that is unable or unwilling to contract with the
Department. The Contractor may not subsequently contract to
provide specialty mental health services unless the Department
elects to contract with the Contractor. (Welf. & Inst. Code §
147122(c)(4).)
4) If the Contractor does not contract with the Department to provide
specialty mental health services, the Department will work with the
Department of Finance and the Controller to obtain funds from the
Contractor in accordance with Government (Govt.) Code 30027.10.
(Welf. & Inst. Code § 147122(d).)
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Exhibit E Al
ADDITIONAL PROVISIONS
B. Contract Renewal
1) This contract may be renewed if the Contractor continues to meet
the statutory and regulatory requirements governing this contract,
as well as the terms and conditions of this contract. Failure to meet
these requirements shall be cause for nonrenewal of the contract.
(42 C.F.R. § 438.708; Welf. & Inst. Code § 14714(b)(1).) The
Department may base the decision to renew on timely completion
of a mutually agreed-upon plan of correction of any deficiencies,
submissions of required information in a timely manner, and/or
other conditions of the contract. (Welf. & Inst. Code § 14714(b)(1).)
2) In the event the contract is not renewed based on the reasons
specified in (1), the Department will notify the Department of
Finance, the fiscal and policy committees of the Legislature, and
the Controller of the amounts to be sequestered from the Mental
Health Subaccount, the Mental Health Equity Account, and the
Vehicle License Fee Collection Account of the Local Revenue Fund
and the Mental Health Account and the Behavioral Health
Subaccount of the Local Revenue Fund 2011, and the Controller
will sequester those funds in the Behavioral Health Subaccount
pursuant to Govt. Code § 30027.10. Upon this sequestration, the
Department will use the funds in accordance with Govt. Code §
30027.10. (Welf. & Inst. Code § 14714(b)(3).)
C. Contract Amendment Negotiations
Should either party during the life of this contract desire a change in this
contract, such change shall be proposed in writing to the other party. The
other party shall acknowledge receipt of the proposal in writing within 10
days and shall have 60 days (or such different period as the parties
mutually may set) after receipt of such proposal to review and consider the
proposal, to consult and negotiate with the proposing party, and to accept
or reject the proposal. Acceptance or rejection may be made orally within
the 60-day period, and shall be confirmed in writing within five days
thereafter. The party proposing any such change shall have the right to
withdraw the proposal at any time prior to acceptance or rejection by the
other party. Any such proposal shall set forth a detailed explanation of the
reason and basis for the proposed change, a complete statement of costs
and benefits of the proposed change and the text of the desired
amendment to this contract that would provide for the change. If the
proposal is accepted, this contract shall be amended to provide for the
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Exhibit E Al
ADDITIONAL PROVISIONS
change mutually agreed to by the parties on the condition that the
amendment is approved by the Department of General Services, if
necessary.
D. Contract Termination
The Department or the Contractor may terminate this contract in
accordance with, and within the given timeframes provided in Cal. a
Code of RegulatieRs., tit.te 9, section 1810.323.
1) DHCS reserves the right to cancel or terminate this Contract
immediately for cause.
2) The term "for cause" shall mean that the Contractor fails to meet
the terms, conditions, and/or responsibilities of this Contract.
3) Contract termination or cancellation shall be effective as of the date
indicated in DHCS' notification to the Contractor. The notice shall
identify any final performance, invoicing or payment requirements.
4) Upon receipt of a notice of termination or cancellation, the
Contractor shall take immediate steps to stop performance and to
cancel, or if cancelation is not possible reduce, subsequent contract
costs.
5) In the event of early termination or cancellation, the Contractor shall
be entitled to payment for all allowable costs authorized under this
Contract and incurred up to the date of termination or cancellation,
including authorized non-cancelable obligations, provided such
expenses do not exceed the stated maximum amounts payable.
6) The Department will immediately terminate this Contract if the
Department finds that there is an immediate threat to the health and
safety of Medi-Cal beneficiaries. Termination of the contract for
other reasons will be subject to reasonable notice to the Contractor
of the Department's intent to terminate, as well as notification to
affected beneficiaries. (Welf. & Inst. Code § 14714(d).)
E. Termination of Obligations
1) All obligations to provide covered services under this contract shall
automatically terminate on the effective date of any termination of
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Exhibit E Al
ADDITIONAL PROVISIONS
this contract. The Contractor shall be responsible for providing
covered services to beneficiaries until the termination or expiration
of the contract and shall remain liable for the processing and
payment of invoices and statements for covered services provided
to beneficiaries prior to such expiration or termination.
2) When Contractor terminates a subcontract with a provider,
Contractor shall make a good faith effort to provide notice of this
termination, within 15 days, to the persons that Contractor, based
on available information, determines have recently been receiving
services from that provider.
F. Contract Disputes
Should a dispute arise between the Contractor and the Department
relating to performance under this contract, other than disputes governed
by a dispute resolution process in Chapter 11 of Division 1, California
Code of Regulations, title 9, or the processes governing the audit appeals
process in Chapter 9 of Division 1, California Code of Regulations, title 9
the Contractor shall follow the Dispute Resolution Process outlined in
provision number 15 of Exhibit D(F) which is attached hereto as part of
this contract.
4. Fulfillment of Obligation
No covenant, condition, duty, obligation, or undertaking continued or made a part
of this contract shall be waived except by written agreement of the parties hereto,
and forbearance or indulgence in any other form or manner by either party in any
regard whatsoever will not constitute a waiver of the covenant, condition, duty,
obligation, or undertaking to be kept, performed or discharged by the party to
which the same may apply. Until performance or satisfaction of all covenants,
conditions, duties, obligations, and undertakings is complete, the other party shall
have the right to invoke any remedy available under this contract, or under law,
notwithstanding such forbearance or indulgence.
5. Additional Provisions
A. Inspection Rights/Record Keeping Requirements
1) Provision number seven (Audit and Record Retention) of Exhibit
D(F), which is attached hereto as part of this Contract, supplements
the following requirements.
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Exhibit E Al
ADDITIONAL PROVISIONS
2) The Contractor, and subcontractors, shall allow the Department,
CMS, the Office of the Inspector General, the Comptroller General
of the United States, and other authorized federal and state
agencies, or their duly authorized designees, to evaluate
Contractor's, and subcontractors', performance under this contract,
including the quality, appropriateness, and timeliness of services
provided, and to inspect, evaluate, and audit any and all records,
documents, and the premises, equipment and facilities maintained
by the Contractor and its subcontractors pertaining to such services
at any time. Contractor shall allow such inspection, evaluation and
audit of its records, documents and facilities, and those of its
subcontractors, for 10 years from the term end date of this Contract
or in the event the Contractor has been notified that an audit or
investigation of this Contract has been commenced, until such time
as the matter under audit or investigation has been resolved,
including the exhaustion of all legal remedies, whichever is later.
(See 42 C.F.R. §§ 438.3(h), 438.230(c)(3)(i-iii).) Records and
documents include, but are not limited to all physical and electronic
records and documents originated or prepared pursuant to
Contractor's or subcontractor's performance under this Contract
including working papers, reports, financial records and documents
of account, beneficiary records, prescription files, subcontracts, and
any other documentation pertaining to covered services and other
related services for beneficiaries.
3) The Contractor, and subcontractors, shall retain, all records and
documents originated or prepared pursuant to Contractor's or
subcontractor's performance under this Contract, including
beneficiary grievance and appeal records identified in Attachment
12, Section 2 and the data, information and documentation
specified in 42 Code of Federal Regulations parts 438.604,
438.606, 438.608, and 438.610 for a period of no less than 10
years from the term end date of this Contract or in the event the
Contractor has been notified that an audit or investigation of this
Contract has been commenced, until such time as the matter under
audit or investigation has been resolved, including the exhaustion
of all legal remedies, whichever is later. (42 C.F.R. § 438.3(u); See
also § 438.3(h).) Records and documents include, but are not
limited to all physical and electronic records and documents
originated or prepared pursuant to Contractor's or subcontractor's
County of Fresno
17-94581 A01
Page 7 of 17
Exhibit E Al
ADDITIONAL PROVISIONS
performance under this Contract including working papers, reports,
financial records and documents of account, beneficiary records,
prescription files, subcontracts, and any other documentation
pertaining to covered services and other related services for
beneficiaries.
B. Notices
Unless otherwise specified in this contract, all notices to be given under
this contract shall be in writing and shall be deemed to have been given
when mailed, to the Department or the Contractor at the following
addresses, unless the contract explicitly requires notice to another
individual or organizational unit:
Department of Health Care Services County of Fresno
Medi-Cal Behavioral McRtal Health 1925 E. Dakota Ave.
,'ervcFViG Division Fresno, CA 93726
15001 Capitol Avenue, MS 2702
P.Q. Rex 9v 97413
Sacramento, CA 95QQ9 741395814
C. Nondiscrimination
1) Consistent with the requirements of applicable federal law, such as
42 Code of Federal Regulations, part 438.3(d)(3) and (4), and
state law, the Contractor shall not engage in any unlawful
discriminatory practices in the admission of beneficiaries,
assignments of accommodations, treatment, evaluation,
employment of personnel, or in any other respect on the basis of
any ground protected under federal or state law, including sex,
race, color, gender, gender identity, religion, marital status, national
origin, ethnic group identification, ancestry, age, sexual
orientation, medical condition, genetic information, or mental or
physical handicap or disability. (42 U.S.C. § 18116; 42 C.F.R. §
438.3(d)(3-4); 45 C.F.R. § 92.2 ); Gov. Code § 11135(a);
Welf. & Inst. Code § 14727(a)(3).)
2) The Contractor shall comply with the provisions of Section 504 of
the Rehabilitation Act of 1973, as amended (codified at 29 U.S.C.
§ 794) n^r+a;n;ng to the prohibitinn e-R of exclusion, denial of
benefits, and discrimination against qualified handiGapped persons
individuals with a disability in a-4Any federally assisted programs
County of Fresno
17-94581 A01
Page 8 of 17
Exhibit E Al
ADDITIONAL PROVISIONS
or activities, and shall comply with the implementing
regulations as detailed in regulations Parts 84 and 85 of Title 45
of the C.F.R., as applicable oigRed by the SeGFetaFy Of Health and
Hurnan Se, e fec�i a e Ii ine 2e � e 197 and foi ind in he Federal
e
Register, Volume e e dated May e
1977.
3) The Contractor shall include the nondiscrimination and compliance
provisions of this contract in all subcontracts to perform work under
this contract.
4) Notwithstanding other provisions of this section, the Contractor may
require a determination of medical necessity pursuant to Cal.+#orRia
Code of RegofatiGRS., tit.fe 9, sections 1820.205, 1830.205 and/or
1830.210, prior to providing covered services to a beneficiary.
D. Relationship of the Parties
The Department and the Contractor are, and shall at all times be deemed
to be, independent agencies. Each party to this contract shall be wholly
responsible for the manner in which it performs the obligations and
services required of it by the terms of this contract. Nothing herein
contained shall be construed as creating the relationship of employer and
employee, or principal and agent, between the parties or any of their
agents or employees. Each party assumes exclusively the responsibility
for the acts of its employees or agents as they relate to the services to be
provided during the course and scope of their employment. The
Department and its agents and employees shall not be entitled to any
rights or privileges of the Contractor's employees and shall not be
considered in any manner to be Contractor employees. The Contractor
and its agents and employees, shall not be entitled to any rights or
privileges of state employees and shall not be considered in any manner
to be state employees.
E. Waiver of Default
Waiver of any default shall not be deemed to be a waiver of any
subsequent default. Waiver of breach of any provision of this contract
shall not be deemed to be a waiver of any other or subsequent breach,
and shall not be construed to be a modification of the terms of this
contract.
County of Fresno
17-94581 A01
Page 9 of 17
Exhibit E Al
ADDITIONAL PROVISIONS
6. Duties of the State
In discharging its obligations under this contract, and in addition to the obligations
set forth in other parts of this contract, the Department shall perform the following
duties:
A. Payment for Services
The Department shall make the appropriate payments set forth in Exhibit
B and take all available steps to secure and pay FFP to the Contractor,
once the Department receives FFP, for claims submitted by the
Contractor. The Department shall notify Contractor and allow Contractor
an opportunity to comment to the Department when questions are posed
by CMS, or when there is a federal deferral, withholding, or disallowance
with respect to claims made by the Contractor.
B. Reviews
The Department shall conduct reviews of access to and quality of care in
Contractor's county at least once every three years and issue reports to
the Contractor detailing findings, recommendations, and corrective action,
as appropriate, pursuant to Cal.;f,� Code of RegulatleRs., tit.le 9,
sections 1810.380 and 1810.385. The Department shall also arrange for
an annual external quality review of the Contractor as required by 42 Code
of Federal Regulations, part 438.350 and Cal.+fornia Code of RegulafiORS.,
tit.le 9, section 1810.380(a)(7).
C. Monitoring for Compliance
When monitoring activities identify areas of non-compliance, the
Department shall issue reports to the Contractor detailing findings,
recommendations, and corrective action. (Cal. Code Reg., tit. 9, §
1810.380.) Failure to comply with required corrective action could lead to
civil penalties, as appropriate, pursuant to Cal. Code Reg., tit. 9, §
1810.385.
D. The Contractor shall prepare and submit a report to the Department that
provides information for the areas set forth in 42 C.F.R. § 438.66(b) and
(c) as outlined in Exhibit A, Attachment 14, Section 7, in the manner
specified by the Department.
County of Fresno
17-94581 A01
Page 10 of 17
Exhibit E Al
ADDITIONAL PROVISIONS
E. If the Contractor has not previously implemented a Mental Health Plan or
Contractor will provide or arrange for the provision of covered benefits to
new eligibility groups, then the Contractor shall develop an Implementation
Plan (as defined in Cal. Code Regs., tit. 9, § 1810.221) that is consistent
with the readiness review requirements set forth in 42 Code of Federal
Regulations, part 438.66(d)(4), and the requirements of Cal. Code Regs.,
tit. 9, § 1810.310 (a). (See 42 C.F.R. § 438.66(d)(1), (4).) The
Department shall review and either approve, disapprove, or request
additional information for each Implementation Plan. Notices of Approval,
Notices of Disapproval and requests for additional information shall be
forwarded to the Contractor within 60 days of the receipt of the
Implementation Plan. (Cal. Code Regs., tit. 9, § 1810.310(b).) A
Contractor shall submit proposed changes to its approved Implementation
Plan in writing to the Department for review. A Contractor shall submit
proposed changes in the policies, processes or procedures that would
modify the Contractor's current Implementation Plan prior to implementing
the proposed changes.(See Cal. Code Regs., tit. 9, § 1810.310 (b)-(c)).
F. The Department shall act promptly to review the Contractor's Cultural
Competence Plan submitted pursuant to Cal. Code Regs., tit. 9, §
1810.410. The Department shall provide a Notice of Approval or a Notice
of Disapproval, including the reasons for the disapproval, to the Contractor
within 60 calendar days after receipt of the plan from the Contractor. If the
Department fails to provide a Notice of Approval or Disapproval, the
Contractor may implement the plan 60 calendar days from its submission
to the Department.
G. Certification of Organizational Provider Sites Owned or Operated by the
Contractor
1) The Department shall certify the organizational provider sites that
are owned, leased or operated by the Contractor, in accordance
with Cal.0fernia Code of Regulations., tit.le 9, section 1810.435, and
the requirements specified in Exhibit A, Attachment 3, Section 6 of
this contract. This certification shall be performed prior to the date
on which the Contractor begins to deliver services under this
contract at these sites and once every three years after that date,
unless the Department determines an earlier date is necessary.
The on-site review required by Cal. Code Regs., tit. 9, §
1810.435(e), shall be conducted of any site owned, leased, or
operated by the Contractor and used for to deliver covered services
County of Fresno
17-94581 A01
Page 11 of 17
Exhibit E Al
ADDITIONAL PROVISIONS
to beneficiaries, except that on-site review is not required for public
school or satellite sites.
2) The Department may allow the Contractor to begin delivering
covered services to beneficiaries at a site subject to on-site review
by the Department prior to the date of the on-site review, provided
the site is operational and has any required fire clearances. The
earliest date the Contractor may begin delivering covered services
at a site subject to on site review by the Department is the date the
Contractor requested certification of the site in accordance with
procedures established by the Department, the date the site was
operational, or the date a required fire clearance was obtained,
whichever date is latest.
3) The Department may allow the Contractor to continue delivering
covered services to beneficiaries at a site subject to on-site review
by the Department as part of the recertification process prior to the
date of the on-site review, provided the site is operational and has
all required fire clearances.
4) Nothing in this section precludes the Department from establishing
procedures for issuance of separate provider identification numbers
for each of the organizational provider sites operated by the
Contractor to facilitate the claiming of FFP by the Contractor and
the Department's tracking of that information.
H. Excluded Providers
1) If the Department learns that the Contractor has a prohibited
affiliation, as described in Attachment 1, Section 2, the
Department:
a) Must notify the Secretary of the noncompliance.
b) May continue an existing agreement with the Contractor
unless the Secretary directs otherwise.
c) May not renew or otherwise extend the duration of an
existing agreement with the Contractor unless the Secretary
provides to the State and to Congress a written statement
describing compelling reasons that exist for renewing or
extending the agreement despite the prohibited affiliations.
County of Fresno
17-94581 A01
Page 12 of 17
Exhibit E Al
ADDITIONAL PROVISIONS
d) Nothing in this section must be construed to limit or
otherwise affect any remedies available to the U.S. under
sections 1128, 1128A or 1128B of the Act. (42 C.F.R.
§438.610(d).)
I. Sanctions
The Department shall conduct oversight and impose sanctions on the
Contractor for violations of the terms of this contract, and applicable
federal and state law and regulations, in accordance with Welf. & Inst.
Code § 14197.74 2(e) and Cal. Code Regs., tit. 9, §§ 1810.380 and
1S2�v10.395.
J. Notification
The Department shall notify beneficiaries of their Medi-Cal specialty
mental health benefits and options available upon termination or expiration
of this contract.
K. Performance Measurement
The Department shall measure the Contractor's performance based on
Medi-Cal approved claims and other data submitted by the Contractor to
the Department using standard measures established by the Department
in consultation with stakeholders.
7. State and Federal Law Governing this Contract
A. Contractor/Subrecipient Designation: the Contractor is considered a
contractor subject to 2 C.F.R Part 200 (45 C.F.R. Part 75).
B. Contractor agrees to comply with all applicable federal and state law,
mG+ diRg SeGt'GRG fthe state plan and waiver, including
but not limited to the statutes and regulations incorporated by reference
below in Sections D, G, and H, CTa„d I=, and applicable sections of
the state plan and waiver in its provision of services as the Mental
Health Plan. Contractor agrees to comply with any changes to these
statutes and regulations that may occur during the contract period and any
new applicable statutes or regulations. These obligations shall n-Gt apply
without the need for a Contract amendment(s). To the extent there is a
conflict between federal or state law or regulation and a provision in this
County of Fresno
17-94581 A01
Page 13 of 17
Exhibit E Al
ADDITIONAL PROVISIONS
contract, Contractor shall comply with the federal or state law or regulation
and the conflicting Contract provision shall no longer be in effect.
C. Contractor agrees to comply with all existing policy letters issued by the
Department. All policy letters issued by the Department subsequent to the
effective date of this Contract shall provide clarification of Contractor's
obligations pursuant to this Contract, and may include instructions to the
Contractor regarding implementation of mandated obligations pursuant to
State or federal statutes or regulations, or pursuant to judicial
interpretation.
D. Federal law:
1) Title 42 United States Code, to the extent that these requirements
are applicable;
2) 42 C.F.R. to the extent that these requirements are applicable;
3) 42 C.F.R. Part 438, Medicaid Managed Care, limited to those
provisions that apply to Prepaid Inpatient Health Plans (PIHPs),
except for the provisions listed in paragraph D and E, below.
4) 42 C.F.R. § 455 to the extent that these requirements are
applicable;
5) 45 C.F.R. § 92.1 et seq. to the extent these requirements are
applicable;
6) Title VI of the Civil Rights Act of 1964;
7) Title IX of the Education Amendments of 1972;
8) Age Discrimination Act of 1975;
9) Rehabilitation Act of 1973;
10) Americans with Disabilities Act;
11) Section 1557 of the Patient Protection and Affordable Care Act;
12) Deficit Reduction Act of 2005;
County of Fresno
17-94581 A01
Page 14 of 17
Exhibit E Al
ADDITIONAL PROVISIONS
13) Balanced Budget Act of 1997;
14) The Contractor shall comply with the provisions of the Copeland
Anti-Kickback Act, which requires that all contracts and
subcontracts in excess of $2000 for construction or repair awarded
by the Contractor and its subcontractors shall include a provision
for compliance with the Copeland Anti-Kickback Act.
15) The Contractor shall comply with the provisions of the Davis-Bacon
Act, as amended, which provides that, when required by Federal
Medicaid program legislation, all construction contracts awarded by
the Contractor and its subcontractors of more than $2,000 shall
include a provision for compliance with the Davis-Bacon Act as
supplemented by Department of Labor regulations.
16) The Contractor shall comply with the provisions of the Contract
Work Hours and Safety Standards Act, as applicable, which
requires that all subcontracts awarded by the Contractor in excess
of $2,000 for construction and in excess of $2,500 for other
subcontracts that involve the employment of mechanics or laborers
shall include a provision for compliance with the Contract Work
Hours and Safety Standards Act.
17) Any applicable federal and state laws that pertain to beneficiary
rights.
18) Should any part of the scope of work under this contract relate
to a State program receiving Federal Financial Participation
(FFP) that is no longer authorized by law (e.g., which has been
vacated by a court of law, or for which CMS has withdrawn
federal authority, or which is the subject of a legislative
repeal), Contractor must do no work on that part after the
effective date of the loss of such program authority. DHCS
must adjust payments to remove costs that are specific to any
State program or activity receiving FFP that is no longer
authorized by law. If Contractor works on a State program or
activity receiving FFP that is no longer authorized by law after
the date the legal authority for the work ends, Contractor will
not be paid for that work. If DHCS has paid Contractor in
advance to work on a no-longer-authorized State program or
activity receiving FFP and under the terms of this contract the
County of Fresno
17-94581 A01
Page 15 of 17
Exhibit E Al
ADDITIONAL PROVISIONS
work was to be performed after the date the legal authority
ended, the payment for that work should be returned to DHCS.
However, if Contractor worked on a State program or activity
receiving FFP prior to the date legal authority ended for that
State program or activity, and DHCS included the cost of
performing that work in its payments to Contractor, Contractor
may keep the payment for that work even if the payment was
made after the date the State program or activity receiving FFP
lost legal authority.
E. The following sections of 42 Code of Federal Regulations, part 438 are
inapplicable to this Contract:
1) §438.3(b) Standard Contract Provisions — Entities eligible for
comprehensive risk contracts
2) §438.3(c) Standard Contract Provisions - Payment
3) §438.3(g) Standard Contract Provisions - Provider preventable
conditions
4) §438.3(o) Standard Contract Provisions - LTSS contract
requirements
5) §438.3(p) Standard Contract Provisions — Special rules for HIOs
6) §438.3(s) Standard Contract Provisions — Requirements for MCOs,
PIHPs, or PAHPs that provide covered outpatient drugs
7) §438.4 Actuarial Soundness
8) §438.5 Rate Development Standards
9) §438.6 Special Contract Provisions Related to Payment
10) §438.7 Rate Certification Submission
11) §438.8 Medical Loss Ratio Standards
12) §438.9 Provisions that Apply to Non-emergency Medical
Transportation
County of Fresno
17-94581 A01
Page 16 of 17
Exhibit E Al
ADDITIONAL PROVISIONS
13) §438.50 State Plan Requirements
14) §438.52 Choice of MCOs, PIHPs, PAHPs, PCCMs, and PCCM
entities
15) §438.56 Disenrollment: requirements and limitations
16) §438.70 Stakeholder engagement when LTSS is delivered through
a managed care program
17) 438.74 State Oversight of the Minimum MLR Requirements
18) §438.104 Marketing
19) 4438.106 Liability for Payment
20) §438.108 Cost Sharing
21) §438.110 Member advisory committee
22) §438.114 Emergency and Post-Stabilization
23) §438.362 Exemption from External Quality Review
24) §438.700-730 Basis for Imposition of Sanctions
25) §438.802 Basic Requirements
26) §438.810 Expenditures for Enrollment Broker Services
27) §438.816 Expenditures for the beneficiary support system for
enrollees using LTSS
F. Specific provisions of 42 Code of Federal Regulations, part 438 relating to
the following subjects are inapplicable to this Contract:
1) Long Terms Services and Supports
2) Managed Long Terms Services and Supports
3) Actuarially Sound Capitation Rates
County of Fresno
17-94581 A01
Page 17 of 17
Exhibit E Al
ADDITIONAL PROVISIONS
4) Medical Loss Ratio
5) Religious or Moral Objections to Delivering Services
6) Family Planning Services
7) Drug Formularies and Covered Outpatient Drugs
G. Pursuant to Welf. & Inst. Code section 14704, a regulation or order
concerning Medi-Cal specialty mental health services adopted by the
State Department of Mental Health pursuant to Division 5 (commencing
with Section 5000), as in effect preceding the effective date of this section,
shall remain in effect and shall be fully enforceable, unless and until the
readoption, amendment, or repeal of the regulation or order by DHCS, or
until it expires by its own terms.
H. State Law:
1) Division 5, Welf. & Inst. Code, to the extent that these requirements
are applicable to the services and functions set forth in this contract
2) Welf. & Inst. Code §§ 14680-14685.1
3) Welf. & Inst. Code §§ 14700-147276
4) Chapter 7, Part 3, Division 9, Welf. & Inst. Code, to the extent that
these requirements are applicable to the services and functions set
forth in this contract
5) Cal. Code Regs., tit. 9, § 1810.100 et. seq. — Medi-Cal Specialty
Mental Health Services
6) Cal. Code Regs., tit. 22, §§ 50951 and 50953
7) Cal. Code Regs., tit. 22, §§ 51014.1 and 51014.2
County of Fresno
17-94581 A01
Page 1 of 5
Exhibit E —Attachment 1 Al
DEFINITIONS
1. The following definitions and the definitions contained in Cal.;f,� Code Gf
Reg6IatiGRS., tit.te 9, sections 1810.100-1850.535 shall apply in this contract. If
there is a conflict between the following definitions and the definitions in
Cal.;f,� Code Gf Regis., tit.te 9, sections 1810.100-1850.535, the
definitions below will apply.
A. "Advance Directives" means a written instruction, such as a living will or
durable power of attorney for health care, recognized under State law
(whether statutory or as recognized by the courts of the State), relating to
the provision of the healthcare when the individual is incapacitated.
B. "Abuse" means, as the term described in, provider practices that are
inconsistent with sound, fiscal, business, or medical practices, and result
in an unnecessary cost to the Medi-Cal program, or in reimbursement for
services that are not medically necessary or that fail to meet professionally
recognized standards for health care. It also includes beneficiary practices
that result in unnecessary cost to the Medi-Cal program. (See 42 C.F.R.
§§ 438.2, 455.2)
C. "Appeal" means a review by the Contractor of an adverse benefit
determination.
D. "Beneficiary" means a Medi-Cal recipient who is currently receiving
services from the Contractor.
E. "Contractor" means County of Fresno.
F. "Covered Specialty Mental Health Services" are defined in Exhibit E,
Attachment 2.
G. "Department" means the California Department of Health Care Services
(DHCS).
H. "Director" means the Director of DHCS.
I. "Discrimination Grievance" means a complaint concerning the
unlawful discrimination on the basis of any characteristic protected
under federal or state law, including sex, race, color, religion,
ancestry, national origin, ethnic group identification, age, mental
disability, physical disability, medical condition, genetic information,
marital status, gender, gender identity, or sexual orientation.
County of Fresno
17-94581 A01
Page 2 of 5
Exhibit E -Attachment 1 Al
DEFINITIONS
J. "Emergency" means a condition or situation in which an individual has a
need for immediate medical attention, or where the potential for such need
is perceived by emergency medical personnel or a public safety agency
(Health & Safety Code § 1797.07).
K. "Fraud" means an intentional deception or misrepresentation made by a
person with the knowledge that the deception could result in some
unauthorized benefit to self or some other person. It includes an act that
constitutes fraud under applicable State and Federal law. (42 C.F.R. §§
438.2, 455.2)
L. "Grievance" means an expression of dissatisfaction about any matter
other than adverse benefit determination. Grievances may include, but are
not limited to, the quality of care or services provided, and aspects of
interpersonal relationships such as rudeness of a provider or employee, or
failure to respect the beneficiary's rights regardless of whether remedial
action is requested. Grievance includes a beneficiary's right to dispute an
extension of time proposed by the Contractor to make an authorization
decision. (42 C.F.R. § 438.400)
M. "Habilitative services and devices" help a person keep, learn, or improve
skills and functioning for daily living. (45 C.F.R. § 156.115(a)(5)(i))
N. "HHS" means the United States Department of Health and Human Service
v "SPenial meansnsYnhiatrist who has a "Gense as a nhvsnia�a
si irgeon in this state and shows eyidenne of haVing nomnleted the
rent i. 1 roi arse of graduate nsYnhiatrir ed inatinn as snenified by the
Amerinan Beard of PSYGhlatry and Neurology in a grogram of training
annredited by the Annreditatinn l eunnil fer GFad late Medical Ed inatien
e
the Amerinan Medinal AssoGiation or the Amerinan Osteenathin
Assn tinn (Gal Ge de Regs tit 9 § 623
P. "Managed Care Organization" (MCO) means an entity that has, or is
seeking to qualify for, a comprehensive risk contract under 42 C.F.R.
Part 438, and is: 1) a Federally qualified HMO that meets the advance
directives requirements of Subpart I of Part 489 of 42 C.F.R.; or, 2)
any public or private entity that meets the advance directive
requirements and is determined by the Secretary of Health and
Human Services to also meet the following conditions: i) makes the
services that it provides to its Medicaid beneficiaries as accessible
(in terms of timeliness, amount, duration, and scope) as those
County of Fresno
17-94581 A01
Page 3 of 5
Exhibit E —Attachment 1 Al
DEFINITIONS
services are to other Medicaid beneficiaries within the area served by
the entity, ii) meet the solvency standards of 42 C.F.R. 438.116. (42
C.F.R. § 438.2)
Q. A "Network Provider" means any provider, group of providers, or entity
that has a network provider agreement with a Mental Health Plan, or a
subcontractor, and receives Medicaid funding directly or indirectly to order,
refer or render covered services as a result of the Department's contract
with a Mental Health Plan. A network provider is not a subcontractor by
virtue of the network provider agreement. (42 C.F.R. § 438.2)
R. "Out-of-network provider" means a provider or group of providers that
does not have a network provider agreement with a Mental Health Plan, or
with a subcontractor. (A provider may be "out of network" for one Mental
Health Plan, but in the network of another Mental Health Plan.)
S. "Out-of-plan provider" has the same meaning as out-of-network provider.
T. "Overpayment" means any payment made to a network provider by a
Mental Health Plan to which the network provider is not entitled
under Title XIX of the Act or any payment to a Mental Health Plan by
a State to which the Mental Health Plan is not entitled to under Title
XIX of the Act. (42 C.F.R. § 438.2)
U. "Provider" means a person or entity who is licensed, certified, or otherwise
recognized or authorized under state law governing the healing arts to
provide specialty mental health services and who meets the standards for
participation in the Medi-Cal program as described in California Code of
Regulations, title 9, Division 1, Chapters 10 or 11 and in Division 3,
Subdivision 1 of Title 22, beginning with Section 50000. Provider includes
but is not limited to licensed mental health professionals, clinics, hospital
outpatient departments, certified day treatment facilities, certified
residential treatment facilities, skilled nursing facilities, psychiatric health
facilities, general acute care hospitals, and acute psychiatric hospitals.
The MHP is a provider when direct services are provided to beneficiaries
by employees of the Mental Health Plan.
V. "Ov p any payment eto a network providerby a
Mental"THealth Plan to LeiMinh the !provider is not entitle u Title XIX of
the AGt or any payment }to a MentalHealth Dian bya State to wrhiGh the
Mental Health Plan is not enrc leed to under Title XIX of the AGt (42 G.F.R.
County of Fresno
17-94581 A01
Page 4 of 5
Exhibit E —Attachment 1 Al
DEFINITIONS
W. "Physician Incentive Plans" mean any compensation arrangement to pay a
physician or physician group that may directly or indirectly have the effect
of reducing or limiting the services provided to any plan enrollee.
X. "PIHP" means Prepaid Inpatient Health Plan. . A Prepaid Inpatient Health
Plan is an entity that:
1) Provides medical services to beneficiaries under contract with the
Department of Health Care Services, and on the basis of prepaid
capitation payments, or other payment arrangement that does not
use state plan rates;
2) Provides, arranges for, or otherwise has responsibility for the
provision of any inpatient hospital or institutional services for its
beneficiaries; and
3) Does not have a comprehensive risk contract. (42 C.F.R. § 438.2)
Y. "Rehabilitation" means a recovery or resiliency focused service activity
identified to address a mental health need in the client plan. This service
activity provides assistance in restoring, improving, and/or preserving a
beneficiary's functional, social, communication, or daily living skills to
enhance self-sufficiency or self regulation in multiple life domains relevant
to the developmental age and needs of the beneficiary. Rehabilitation also
includes support resources, and/or medication education. Rehabilitation
may be provided to a beneficiary or a group of beneficiaries. (California's
Medicaid State Plan, State Plan Amendment 10-016, Attachment 3.1-A,
Supplement 3, p. 2a.)
Z. "Satellite site" means a site owned, leased or operated by an
organizational provider at which specialty mental health services are
delivered to beneficiaries fewer than 20 hours per week, or, if located at a
multiagency site at which specialty mental health services are delivered by
no more than two employees or contractors of the provider.
AA. "Specialist" means a psychiatrist who has a license as a physician
and surgeon in this state and shows evidence of having completed
the required course of graduate psychiatric education as specified
by the American Board of Psychiatry and Neurology in a program of
training accredited by the Accreditation Council for Graduate
County of Fresno
17-94581 A01
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Exhibit E —Attachment 1 Al
DEFINITIONS
Medical Education, the American Medical Association, or the
American Osteopathic Association. (Cal. Code Regs., tit. 9 § 623.)
BB. "Subcontract" means an agreement entered into by the Contractor with
any of the following:
1) Any other organization or person who agrees to perform any
administrative function or service for the Contractor specifically
related to securing or fulfilling the Contractor's obligations to the
Department under the terms of this contract.
2) "Subcontractor" means an individual or entity that has a contract
with an MCO, PIHP, PAHP, or PCCM entity that relates directly or
indirectly to the performance of the MCO's, PIHP's, PAHP's, or
PCCM entity's obligations under its contract with the State. A
network provider is not a subcontractor by virtue of the network
provider agreement with the MCO, PIHP, or PAHP.
Notwithstanding the foregoing, for purposes of Exhibit D(F) the term
"subcontractor" shall include network providers.
County of Fresno
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Exhibit E —Attachment 2 Al
SERVICE DEFINITIONS
1. The Contractor shall provide, or arrange and pay for, the following medically
necessary covered specialty mental health services to beneficiaries of Fresno
County. Services shall be provided based on medical necessity criteria, in
accordance with an individualized Client Plan, and approved and authorized
according to State of California requirements. Services include:
A. Mental Health Services Individual or group therapies and interventions are
designed to provide a reduction of mental disability and restoration,
improvement or maintenance of functioning consistent with the goals of
learning, development, independent living, and enhanced self-sufficiency.
These services are separate from those provided as components of adult
residential services, crisis intervention, crisis stabilization, day
rehabilitation, or day treatment intensive. Service activities may include,
but are not limited to:
1) Assessment - A service activity designed to evaluate the current
status of mental, emotional, or behavioral health. Assessment
includes, but is not limited to, one or more of the following: mental
status determination, analysis of the clinical history, analysis of
relevant cultural issues and history; diagnosis; and the use of
mental health testing procedures.
2) Plan Development - A service activity that consists of development
of client plans, approval of client plans, and/or monitoring and
recording of progress.
3) Therapy - A service activity that is a therapeutic intervention that
focuses primarily on symptom reduction as a means to reduce
functional impairments. Therapy may be delivered to an individual
or group and may include family therapy at which the client is
present.
4) Rehabilitation - A service activity that includes, but is not limited to,
assistance, improving, maintaining or restoring functional skills,
daily living skills, social and leisure skills, grooming and personal
hygiene skills; obtaining support resources; and/or obtaining
medication education.
5) Collateral - A service activity involving a significant support person
in the beneficiary's life for the purpose of addressing the mental
health needs of the beneficiary in terms of achieving goals of the
beneficiary's client plan. Collateral may include, but is not limited
County of Fresno
17-94581 A01
Page 2 of 6
Exhibit E —Attachment 2 Al
SERVICE DEFINITIONS
to, consultation and training of the significant support person(s) to
assist in better utilization of mental health services by the client,
consultation and training of the significant support person(s) to
assist in better understanding of mental illness, and family
counseling with the significant support person(s) in achieving the
goals of the client plan. The client may or may not be present for
this service activity.
B. Medication Support Services include prescribing, administering,
dispensing and monitoring of psychiatric medications or biologicals that
are necessary to alleviate the symptoms of mental illness. Service
activities may include but are not limited to: evaluation of the need for
medication; evaluation of clinical effectiveness and side effects; obtaining
informed consent; instruction in the use, risks and benefits of, and
alternatives for, medication; collateral and plan development related to the
delivery of service and/or assessment for the client; prescribing,
administering, dispensing and monitoring of psychiatric medications or
biologicals; and medication education.
C. Day Treatment Intensive are a structured, multi-disciplinary program of
therapy that may be used as an alternative to hospitalization, or to avoid
placement in a more restrictive setting, or to maintain the client in a
community setting and which provides services to a distinct group of
beneficiaries who receive services for a minimum of three hours per day
(half-day) or more than four hours per day (full-day). Service activities may
include, but are not limited to, assessment, plan development, therapy,
rehabilitation and collateral. Collateral addresses the mental health needs
of the beneficiary to ensure coordination with significant others and
treatment providers.
D. Day Rehabilitation services are a structured program of rehabilitation and
therapy with services to improve, maintain or restore personal
independence and functioning, consistent with requirements for learning
and development and which provides services to a distinct group of
beneficiaries who receive services for a minimum of three hours per day
(half-day) or more than four hours per day (full-day). Service activities may
include, but are not limited to assessment, plan development, therapy,
rehabilitation and collateral. Collateral addresses the mental health needs
of the beneficiary to ensure coordination with significant others and
treatment providers.
County of Fresno
17-94581 A01
Page 3 of 6
Exhibit E —Attachment 2 Al
SERVICE DEFINITIONS
E. Crisis Intervention services last less than 24 hours and are for, or on
behalf of, a beneficiary for a condition that requires more timely response
than a regularly scheduled visit. Service activities include, but are not
limited to, assessment, collateral and therapy. Crisis Intervention services
may either be face-to-face or by telephone with the beneficiary or the
beneficiary's significant support person and may be provided anywhere in
the community.
F. Crisis Stabilization services last less than 24 hours and are for, or on
behalf of, a beneficiary for a condition that requires a more timely
response than a regularly scheduled visit. Service activities include but
are not limited to one or more of the following: assessment, collateral, and
therapy. Collateral addresses the mental health needs of the beneficiary
to ensure coordination with significant others and treatment providers.
G. Adult Residential Treatment Services are rehabilitative services provided
in a non-institutional, residential setting for beneficiaries who would be at
risk of hospitalization or other institutional placement if they were not
receiving residential treatment services. The services include a wide
range of activities and services that support beneficiaries in their effort to
restore, maintain, and apply interpersonal and independent living skills
and to access community support systems. Service activities may include
assessment, plan development, therapy, rehabilitation, and collateral.
Collateral addresses the mental health needs of the beneficiary to ensure
coordination with significant others and treatment providers.
H. Crisis Residential services provide an alternative to acute psychiatric
hospital services for beneficiaries who otherwise would require
hospitalization. The CRS programs for adults provide normalized living
environments, integrated into residential communities. The services follow
a social rehabilitation model that integrates aspects of emergency
psychiatric care, psychosocial rehabilitation, milieu therapy, case
management and practical social work.
I. Psychiatric Health Facility Services—A Psychiatric Health Facility is a
facility licensed under the provisions beginning with Section 77001 of
Chapter 9, Division 5, Title 22 of the California Code of Regulations.
"Psychiatric Health Facility Services" are therapeutic and/or rehabilitative
services provided in a psychiatric health facility on an inpatient basis to
beneficiaries who need acute care, which meets the criteria of Section
1820.205 of Chapter 11, Division 1 , Title 9 of the California Code of
Regulations, and whose physical health needs can be met in an affiliated
County of Fresno
17-94581 A01
Page 4 of 6
Exhibit E —Attachment 2 Al
SERVICE DEFINITIONS
general acute care hospital or in outpatient settings. These services are
separate from those categorized as "Psychiatric Inpatient Hospital".
J. Intensive Care Coordination (ICC) is a targeted case management service
that facilitates assessment of, care planning for and coordination of
services to beneficiaries under age 21 who are eligible for the full scope of
Medi-Cal services and who meet medical necessity criteria for this service.
ICC service components include: assessing; service planning and
implementation; monitoring and adapting; and transition. ICC services are
provided through the principles of the Integrated Core Practice Model
(ICPM), including the establishment of the Child and Family Team (CFT)
to ensure facilitation of a collaborative relationship among a child yeu##,
his/her family and involved child-serving systems. The CFT is comprised
of— as appropriate, both formal supports, such as the care coordinator,
providers, case managers from child-serving agencies, and natural
supports, such as family members, neighbors, friends, and clergy and all
ancillary individuals who work together to develop and implement the
client plan and are responsible for supporting the childiyeuth and family in
attaining their goals. ICC also provides an ICC coordinator who:
1) Ensures that medically necessary services are accessed,
coordinated and delivered in a strength-based, individualized,
family/yeuth- hild driven and culturally and linguistically competent
manner and that services and supports are guided by the needs of
the child/youth;
2) Facilitates a collaborative relationship among the child/yew,
his/her family and systems involved in providing services to the
chiId/yeut#;
3) Supports the parent/caregiver in meeting their child/youth's needs;
4) Helps establish the CFT and provides ongoing support; and
5) Organizes and matches care across providers and child serving
systems to allow the child/yeeth to be served in his/her community
K. Intensive Home Based Services (IHBS) are individualized, strength-based
interventions designed to ameliorate mental health conditions that
interfere with a child #'s functioning and are aimed at helping the
child/youth build skills necessary for successful functioning in the home
and community and improving the child/yeuth's family's ability to help the
County of Fresno
17-94581 A01
Page 5 of 6
Exhibit E —Attachment 2 Al
SERVICE DEFINITIONS
child/youth successfully function in the home and community. IHBS
services are provided according to an individualized treatment plan
developed in accordance with the Integrated Core Practice Model (ICPM)
by the Child and Family Team (CFT) in coordination with the family's
overall service plan which may include IHBS. Service activities may
include, but are not limited to assessment, plan development, therapy,
rehabilitation and collateral. IHBS is provided to beneficiaries under 21
who are eligible for the full scope of Medi-Cal services and who meet
medical necessity criteria for this service.
L. Therapeutic Behavioral Services JBS) are intensive, individualized, short-
term outpatient treatment interventions for beneficiaries up to age 21.
Individuals receiving these services have serious emotional disturbances
(SED), are experiencing a stressful transition or life crisis and need
additional short-term, specific support services to accomplish outcomes
specified in the written treatment plan.
M. Therapeutic Foster Care (TFC) Services model allows for the provision of
short-term, intensive, highly coordinated, trauma informed and
individualized specialty mental health services SMHS activities (plan
development, rehabilitation and collateral) to children and youth up to age
21 who have complex emotional and behavioral needs and who are
placed with trained, intensely supervised and supported TFC parents. The
TFC parent serves as a key participant in the therapeutic treatment
process of the child or yeuth. The TFC parent will provide trauma informed
interventions that are medically necessary for the child or youth. TFC is
intended for children and youth who require intensive and frequent mental
health support in a family environment. The TFC service model allows for
the provision of certain specialty mental health services SMHS activities
(plan development, rehabilitation and collateral) available under the
EPSDT benefit as a home-based alternative to high level care in
institutional settings such as group homes and an alternative to Short
Term Residential Therapeutic Programs (STRTPs).
N. PSYGhiatrin inpatient Hospital Psychiatric Inpatient Hospital Services
include both acute psychiatric inpatient hospital services and
administrative day services. Acute psychiatric inpatient hospital services
are provided to beneficiaries for whom the level of care provided in a
hospital is medically necessary to diagnose or treat a covered mental
illness. Administrative day services are inpatient hospital services
provided to beneficiaries who were admitted to the hospital for an acute
psychiatric inpatient hospital service and the beneficiary's stay at the
County of Fresno
17-94581 A01
Page 6 of 6
Exhibit E —Attachment 2 Al
SERVICE DEFINITIONS
hospital must be continued beyond the beneficiary's need for acute
psychiatric inpatient hospital services due to lack of residential placement
options at non-acute residential treatment facilities that meet the needs of
the beneficiary.
Psychiatric inpatient hospital services are provided by SD/MC hospitals
and FFS/MC hospitals. MHPs claim reimbursement for the cost of
psychiatric inpatient hospital services provided by SD/MC hospitals
through the SD/MC claiming system. FFS/MC hospitals claim
reimbursement for the cost of psychiatric inpatient hospital services
through the Fiscal Intermediary. MHPs are responsible for authorization
of psychiatric inpatient hospital services reimbursed through either billing
system. For SD/MC hospitals, the daily rate includes the cost of any
needed professional services. The FFS/MC hospital daily rate does not
include professional services, which are billed separately from the
FFS/MC inpatient hospital services via the SD/MC claiming system.
p Targeted Case MaRageMeRt Targeted case management is a service that
assists a beneficiary in accessing needed medical, educational, social,
prevocational, vocational, rehabilitative, or other community services. The
service activities may include, but are not limited to, communication,
coordination and referral; monitoring service delivery to ensure beneficiary
access to services and the service delivery system; monitoring of the
beneficiary's progress, placement services, and plan development. TCM
services may be face-to-face or by telephone with the client or significant
support persons and may be provided anywhere in the community.
Additionally, services may be provided by any person determined by the
MHP to be qualified to provide the service, consistent with the scope of
practice and state law.
Contractor Certification Clauses
CCC 04/2017
CERTIFICATION
I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am
duly authorized to legally bind the prospective Contractor to the clause(s) listed
below. This certification is made under the laws of the State of California.
Contractor/Bidder Firm Name (Printed) Federal ID Number
County of Fresno By (Authorized Signature) ATTEST:
�Y Iwo BE rk of
E.SEIoar EL
of
Clerk of the Board of Supervisors
County of Fresno,State of California
Printed Name and Title of Person Signing By '�fjrs� �?�t�`
Deputv
Brian Pacheco Chairman of the Board of Supervisors of the County of Fresno
Date Executed Executed in the County of
3 _ ;Z9 ,?- a.9- Fresno
CONTRACTOR CERTIFICATION CLAUSES
1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied with the
nondiscrimination program requirements. (Gov. Code §12990 (a-f) and CCR, Title 2,
Section 11102) (Not applicable to public entities.)
2. DRUG-FREE WORKPLACE REQUIREMENTS: Contractor will comply with the
requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-free
workplace by taking the following actions:
a. Publish a statement notifying employees that unlawful manufacture, distribution,
dispensation, possession or use of a controlled substance is prohibited and specifying
actions to be taken against employees for violations.
b. Establish a Drug-Free Awareness Program to inform employees about:
1) the dangers of drug abuse in the workplace;
2) the person's or organization's policy of maintaining a drug-free workplace;
3) any available counseling, rehabilitation and employee assistance programs; and,
4) penalties that may be imposed upon employees for drug abuse violations.
c. Every employee who works on the proposed Agreement will:
1) receive a copy of the company's drug-free workplace policy statement; and,
2) agree to abide by the terms of the company's statement as a condition of employment
on the Agreement.
Failure to comply with these requirements may result in suspension of payments under
the Agreement or termination of the Agreement or both and Contractor may be ineligible
for award of any future State agreements if the department determines that any of the
following has occurred: the Contractor has made false certification, or violated the
certification by failing to carry out the requirements as noted above. (Gov. Code §8350 et
seq.)
3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: Contractor certifies that
no more than one (1) final unappealable finding of contempt of court by a Federal court
has been issued against Contractor within the immediately preceding two-year period
because of Contractor's failure to comply with an order of a Federal court, which orders
Contractor to comply with an order of the National Labor Relations Board. (Pub. Contract
Code §10296) (Not applicable to public entities.)
4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO
REQUIREMENT: Contractor hereby certifies that Contractor will comply with the
requirements of Section 6072 of the Business and Professions Code, effective January 1,
2003.
Contractor agrees to make a good faith effort to provide a minimum number of hours of
pro bono legal services during each year of the contract equal to the lessor of 30
multiplied by the number of full time attorneys in the firm's offices in the State, with the
number of hours prorated on an actual day basis for any contract period of less than a full
year or 10% of its contract with the State.
Failure to make a good faith effort may be cause for non-renewal of a state contract for
legal services, and may be taken into account when determining the award of future
contracts with the State for legal services.
5. EXPATRIATE CORPORATIONS: Contractor hereby declares that it is not an
expatriate corporation or subsidiary of an expatriate corporation within the meaning of
Public Contract Code Section 10286 and 10286.1 , and is eligible to contract with the
State of California.
6. SWEATFREE CODE OF CONDUCT:
a. All Contractors contracting for the procurement or laundering of apparel, garments or
corresponding accessories, or the procurement of equipment, materials, or supplies,
other than procurement related to a public works contract, declare under penalty of
perjury that no apparel, garments or corresponding accessories, equipment, materials, or
supplies furnished to the state pursuant to the contract have been laundered or produced
in whole or in part by sweatshop labor, forced labor, convict labor, indentured labor under
penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor,
or with the benefit of sweatshop labor, forced labor, convict labor, indentured labor under
penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor.
The contractor further declares under penalty of perjury that they adhere to the Sweatfree
Code of Conduct as set forth on the California Department of Industrial Relations website
located at www.dir.ca.gov, and Public Contract Code Section 6108.
b. The contractor agrees to cooperate fully in providing reasonable access to the
contractor's records, documents, agents or employees, or premises if reasonably
required by authorized officials of the contracting agency, the Department of Industrial
Relations, or the Department of Justice to determine the contractor's compliance with the
requirements under paragraph (a).
7. DOMESTIC PARTNERS: For contracts of $100,000 or more, Contractor certifies that
Contractor is in compliance with Public Contract Code section 10295.3.
8. GENDER IDENTITY: For contracts of $100,000 or more, Contractor certifies that
Contractor is in compliance with Public Contract Code section 10295.35.
DOING BUSINESS WITH THE STATE OF CALIFORNIA
The following laws apply to persons or entities doing business with the State of California.
1 . CONFLICT OF INTEREST: Contractor needs to be aware of the following provisions
regarding current or former state employees. If Contractor has any questions on the
status of any person rendering services or involved with the Agreement, the awarding
agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
1). No officer or employee shall engage in any employment, activity or enterprise from
which the officer or employee receives compensation or has a financial interest and
which is sponsored or funded by any state agency, unless the employment, activity or
enterprise is required as a condition of regular state employment.
2). No officer or employee shall contract on his or her own behalf as an independent
contractor with any state agency to provide goods or services.
Former State Employees (Pub. Contract Code §10411):
1). For the two-year period from the date he or she left state employment, no former state
officer or employee may enter into a contract in which he or she engaged in any of the
negotiations, transactions, planning, arrangements or any part of the decision-making
process relevant to the contract while employed in any capacity by any state agency.
2). For the twelve-month period from the date he or she left state employment, no former
state officer or employee may enter into a contract with any state agency if he or she was
employed by that state agency in a policy-making position in the same general subject
area as the proposed contract within the 12-month period prior to his or her leaving state
service.
If Contractor violates any provisions of above paragraphs, such action by Contractor shall
render this Agreement void. (Pub. Contract Code §10420)
Members of boards and commissions are exempt from this section if they do not receive
payment other than payment of each meeting of the board or commission, payment for
preparatory time and payment for per diem. (Pub. Contract Code §10430 (e))
2. LABOR CODEMORKERS' COMPENSATION: Contractor needs to be aware of the
provisions which require every employer to be insured against liability for Worker's
Compensation or to undertake self-insurance in accordance with the provisions, and
Contractor affirms to comply with such provisions before commencing the performance of
the work of this Agreement. (Labor Code Section 3700)
3. AMERICANS WITH DISABILITIES ACT: Contractor assures the State that it complies
with the Americans with Disabilities Act (ADA) of 1990, which prohibits discrimination on
the basis of disability, as well as all applicable regulations and guidelines issued pursuant
to the ADA. (42 U.S.C. 12101 et seq.)
4. CONTRACTOR NAME CHANGE: An amendment is required to change the
Contractor's name as listed on this Agreement. Upon receipt of legal documentation of
the name change the State will process the amendment. Payment of invoices presented
with a new name cannot be paid prior to approval of said amendment.
5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:
a. When agreements are to be performed in the state by corporations, the contracting
agencies will be verifying that the contractor is currently qualified to do business in
California in order to ensure that all obligations due to the state are fulfilled.
b. "Doing business" is defined in R&TC Section 23101 as actively engaging in any
transaction for the purpose of financial or pecuniary gain or profit. Although there are
some statutory exceptions to taxation, rarely will a corporate contractor performing within
the state not be subject to the franchise tax.
c. Both domestic and foreign corporations (those incorporated outside of California) must
be in good standing in order to be qualified to do business in California. Agencies will
determine whether a corporation is in good standing by calling the Office of the Secretary
of State.
6. RESOLUTION: A county, city, district, or other local public body must provide the State
with a copy of a resolution, order, motion, or ordinance of the local governing body which
by law has authority to enter into an agreement, authorizing execution of the agreement.
7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the Contractor shall
not be: (1) in violation of any order or resolution not subject to review promulgated by the
State Air Resources Board or an air pollution control district; (2) subject to cease and
desist order not subject to review issued pursuant to Section 13301 of the Water Code for
violation of waste discharge requirements or discharge prohibitions; or (3) finally
determined to be in violation of provisions of federal law relating to air or water pollution.
8. PAYEE DATA RECORD FORM STD. 204: This form must be completed by all
contractors that are not another state agency or other governmental entity.