HomeMy WebLinkAboutAgreement A-22-452 with DHCS 22-20101.pdf SCO ID: 4260-2220101 Agreement No. 22-452
STATE OF CALIFORNIA-DEPARTMENT OF GENERAL SERVICES
STANDARD AGREEMENT AGREEMENT NUMBER PURCHASING AUTHORITY NUMBER(If Applicable)
STD 213(Rev.04/2020) 22-20101
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 1,2022
THROUGH END DATE
June 30,2027
3.The maximum amount of this Agreement is:
$0.00(Zero Dollars and Zero Cents)
4.The parties agree to comply with the terms and conditions of the following exhibits,which are by this reference made a part of the Agreement.
Exhibits Title Pages
Exhibit A Scope of Work 2 Pages
Exhibit A-
Attachment Organization and Administration 6 Pages
1
Exhibit A-
Attachment Scope of Services 10 Pages
2
+ Exhibit A-
_ Attachment Financial Requirements 5 Pages
3
+ Exhibit A-
_ Attachment Management Information Systems 3 Pages
4
+ Exhibit A-
_ Attachment Quality Improvement System 6 Pages
5
+ Exhibit A-
_ Attachment Utilization Management Program 3 Pages
6
+ Exhibit A-
_ Attachment Access and Availability of Resources 4 Pages
7
+ Exhibit A-
_ Attachment Provider Network 12 Pages
8
+ Exhibit A-
_ Attachment Documentation Requirements 1 Page
9
+ Exhibit A-
_ Attachment Coordination and Continuity of Care 3 Pages
10
+ Exhibit A-
_ Attachment Information Requirements 12 Pages
11
Page 1 of 3
SCO ID: 4260-2220101
STATE OF CALIFORNIA-DEPARTMENT OF GENERAL SERVICES
STANDARD AGREEMENT AGREEMENT NUMBER PURCHASING AUTHORITY NUMBER(If Applicable)
STD 213(Rev.04/2020) 22-201 01
Exhibits Title Pages
+ ExhibitA-
Attachment Beneficiary Problem Resolution 23 Pages
12
+ Exhibit A-
Attachment Program Integrity 7 Pages
13
+ Exhibit A-
Attachment Reporting Requirements 3 Pages
14
+ Exhibit A-
Attachment Peer Support Services 2 Pages
15
+
Exhibit B Budget Detail and Payment Provisions 6 Pages
Exhibit C* General Terms and Conditions(04/2017)
+ Special Terms and Conditions
Exhibit D(F) apply agreement.)
39 Pages
(Notwithstanding Provisions 2,3,4,6,8,13, 15,23,26,30,and 31 which do not pp y to this
Exhibit E Additional Provisions 17 Pages
+ Exhibit E
Attachment Definitions 6 Pages
1
-= Exhibit E
Attachment Service Definitions 6 Pages
2
Exhibit F Privacy and Security Provisions 6 Pages
Items shown wit an asterisk(*),are hereby incorporated by reference and made part of this agreementas if attached hereto.
These documents can be viewed at https✓/www.dgs.ca.gov/OLS/Resources
IN WITNESS WHEREOF,THIS AGREEMENT HAS BEEN EXECUTED BYTHE PARTIES HERETO.
CONTRACTOR
CONTRACTOR NAME(if other than an individual,state whether a corporation,partnership,etc.)
County of Fresno
CONTRACTOR BUSINESS ADDRESS CITY STATE ZIP
1925 E.Dakota Ave. Fresno CA 93726
PRINTED NAME OF PERSON SIGNING TITLE
Brian Pacheco Chairman to the Board of Supervisors of the County of Fresno
CONT ACTO U HORIZED SIGNATURE DATE SIGNED
/v
ATTEST:
BERNICE E.SEIDEL
Clerk of the Board of Supervisors
County of Fresno State of California
By Deputy
Page 2 of 3
SCO ID: 4260-2220101
STATE OF CALIFORNIA-DEPARTMENT OF GENERAL SERVICES
STANDARD AGREEMENT AGREEMENT NUMBER PURCHASING AUTHORITY NUMBER(If Applicable)
STD 213(Rev.04/2020) 22-20101
STATE OF CALIFORNIA
t
CONTRACTING AGENCY NAME
Department of Health Care Services
CONTRACTING AGENCY ADDRESS CITY STATE ZIP
1501 Capitol Ave,MS 4200 Sacramento CA 95814
PRINTED NAME OF PERSON SIGNING TITLE
Robert M. Strom Staff Services Manager If
CONTRACTING AGENCY AUTHORIZED S N TU E DATE SIGNED
DEC 3 2022
CALIFORNIA DEPARTMENT OF GENERAL SERVICES APPROVAL EXEMPTION(If Applicable)
WIC 14703
Paqe 3 of 3
County of Fresno
22-20101
Page 1 of 2
Exhibit A
SCOPE OF WORK
1. Service Overview
The 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 Services County of Fresno
Erika Cristo Susan Holt, Director of
Telephone: (916) 713-8546 Behavioral Health
Email: Erika.Cristo(a)_dhcs.ca.gov Telephone: 559-600-9180
Fax: 559-600-7905
Email:
sholt@fresnocountyca.gov
B. Direct all inquiries to:
Department of Health Care Services County of Fresno
Medi-Cal Behavioral Health Attention: Joseph Rangel
Division/Program Policy Section 1925 E. Dakota Avenue
Attention: Dee Taylor Fresno, CA 92725
1501 Capitol Avenue, MS 2702 Telephone: 559-600-6055
Sacramento, CA, 95814 Fax: 559-600-6089
Telephone: (916) 713-8509 Email:
Email: Dee.Taylor(o)_dhcs.ca.gov rangeja@fresnocountyca.gov
County of Fresno
22-20101
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Exhibit A
SCOPE OF WORK
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.
5. General Authority
This Contract is entered into in accordance with the Welfare and Institutions
(Welf. & Inst.) Code § 14680 through §14727. 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. Electronic and IT Accessibility Requirements Under the Rehabilitation Act
of 1973 and the Americans with Disabilities Act of 1990
The Contractor agrees to ensure that deliverables developed and produced,
pursuant to this Agreement shall comply with the accessibility requirements of
Section 508 of the Rehabilitation Act of 1973 as amended (29 U.S.C. § 794 (d)),
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. 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 section 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 15 for a detailed description of the services
to be performed.
County of Fresno
22-20101
Page 1 of 6
Exhibit A— Attachment 1
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 (Cal. Code Regs.) Title (tit.) 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. § 1395uo)(2)) of the Social Security Act. (42
C.F.R. §§ 438.214(d)(1), 438.610(b).)
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
22-20101
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Exhibit A— Attachment 1
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, the
Contractor may delegate duties and obligations of Contractor under this contract
to subcontracting entities if the 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. § 438.230(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
22-20101
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Exhibit A— Attachment 1
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.
8) Provisions for full and partial revocation of the subcontract,
delegated activities or obligations, or application of other remedies
County of Fresno
22-20101
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Exhibit A— Attachment 1
ORGANIZATION AND ADMINISTRATION
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.
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).) 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. The
Department's inspection shall occur at the subcontractor's place of
business, premises or physical facilities. (42 C.F.R. §
438.230(c)(3)(iv).)
11) Subcontractor shall maintain books and recordsof its work pursuant
to its subcontract, 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.
13) Subcontractor's agreement to hold harmless both the State and
beneficiaries in the event the Contractor cannot or does not pay for
County of Fresno
22-20101
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Exhibit A— Attachment 1
ORGANIZATION AND ADMINISTRATION
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. The 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).)
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
County of Fresno
22-20101
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Exhibit A— Attachment 1
ORGANIZATION AND ADMINISTRATION
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. The 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) The Contractor shall submit documentation to the Department of
employees (current and former State employees) who may present
a conflict of interest.
County of Fresno
22-20101
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Exhibit A— Attachment 2
SCOPE OF SERVICES
1. Criteria for Beneficiaries to Access Specialty Mental Health Services
Effective January 1, 2022, the Contractor shall implement the criteria for access
to SMHS (except for psychiatric inpatient hospital and psychiatric health facility
services) established below, update the Contractor's policies and procedures as
needed to ensure compliance with this policy effective January 1, 2022, and
communicate these updates to providers as necessary.
In addition, the Contractor shall update beneficiary handbooks, manuals, and
related materials to ensure the criteria for SMHS for individuals under 21 years of
age and for adults is accurately reflected in all materials, including materials
reflecting the responsibility of Medi-Cal managed care plans and the Fee for
Service delivery system for covering non-specialty mental health services.(BHIN
21-073).
A. Pursuant to Welf. & Inst. Code section 14184.402(a) the following
definitions of "medical necessity" or "medically necessary" apply:
1) For individuals 21 years of age or older, a service is "medically
necessary" or a "medical necessity" when it is reasonable and
necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe pain as set forth in Welfare and
Institutions Code section 14059.5
2) For individuals under 21 years of age, a service is "medically
necessary" or a "medical necessity" if the service meets the standards
set forth in Section 1396d(r)(5) of Title 42 of the United States Code.
This section requires provision of all Medicaid-coverable services
needed to correct and ameliorate mental illness and conditions.
Federal guidance from the Centers for Medicare & Medicaid Services
makes it clear that services need not be curative or restorative to
ameliorate a mental health condition. All mental health services that
are not covered under Medi-Cal Fee For Service (FFS) or by Managed
Care Plans as non-specialty mental health services as established in
W&I Code section 14184.402(b) that sustain, support, improve, or
make more tolerable a mental health condition are considered to
ameliorate the mental health condition are thus medically necessary
and covered as EPSDT services and the Contractor shall cover them
for beneficiaries who meet the criteria for access to the specialty
mental health delivery system.
County of Fresno
22-20101
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Exhibit A— Attachment 2
SCOPE OF SERVICES
Services provided to a beneficiary must be medically necessary and
clinically appropriate to address the beneficiary's presenting condition.
B. Criteria for Adult Beneficiaries to Access the Specialty Mental Health
Services Delivery System
For beneficiaries 21 years of age or older, the Contractor shall provide
covered specialty mental health services for beneficiaries who meet both
of the following criteria, (1) and (2) below:
1. The beneficiary has one or both of the following:
a. Significant impairment, where impairment is defined as distress,
disability, or dysfunction in social, occupational, or other
important activities
b. A reasonable probability of significant deterioration in an
important area of life functioning
AND
2. The beneficiary's condition as described in paragraph (1) is due to
either of the following:
a. A diagnosed mental health disorder, according to the criteria of
the current editions of the Diagnostic and Statistical Manual of
Mental Disorders and the International Statistical Classification
of Diseases and Related Health Problems
b. A suspected mental disorder that has not yet been diagnosed
C. Criteria for Beneficiaries under Age 21 to Access the Specialty Mental
Health Services Delivery System
For enrolled beneficiaries under 21 years of age, Contractor shall provide
all medically necessary specialty mental health services required pursuant
to Section 1396d(r) of Title 42 of the United States Code. Covered
specialty mental health services shall be provided to enrolled beneficiaries
who meet either of the following criteria:
1) The beneficiary has a condition placing them at high risk for a mental
health disorder due to experience of trauma evidenced by any of the
following: scoring in the high-risk range under a trauma screening tool
County of Fresno
22-20101
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Exhibit A— Attachment 2
SCOPE OF SERVICES
approved by the department, involvement in the child welfare system,
juvenile justice involvement, or experiencing homelessness.
OR
2) The beneficiary meets both of the following requirements in a and b
below:
a. The beneficiary has at least one of the following:
i. A significant impairment
ii. A reasonable probability of significant deterioration in an
important area of life functioning
iii. A reasonable probability of not progressing developmentally
as appropriate
iv. A need for specialty mental health services, regardless of
presence of impairment, that are not included within the
mental health benefits that a Medi-Cal managed care plan is
required to provide
AND
b. The beneficiary's condition as described in subparagraph (A) is
due to one of the following:
i. A diagnosed mental health disorder, according to the criteria
of the current editions of the Diagnostic and Statistical
Manual of Mental Disorders and the International Statistical
Classification of Diseases and Related Health Problems
ii. A suspected mental health disorder that has not yet been
diagnosed
iii. Significant trauma placing the beneficiary at risk of a future
mental health condition, based on the assessment of a
licensed mental health professional
2. Provision of Services
A. The Contractor shall provide or arrange, and pay for, the following
medically necessary covered specialty mental health services to
beneficiaries who meet access criteria for receiving specialty mental
health services. See Exhibit E, Attachment 2, Service Definitions, for
detailed descriptions of the specialty mental health services listed below-
1) Mental health Services;
County of Fresno
22-20101
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Exhibit A— Attachment 2
SCOPE OF 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;
15) Targeted Case Management;
16) Peer Support Services (If the Contractor has opted to provide Peer
Support Services and has been approved by DHCS, the Contractor
shall comply with the peer support services provisions in
Attachment 15); and
17) For beneficiaries under the age of 21, 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)).
County of Fresno
22-20101
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Exhibit A— Attachment 2
SCOPE OF SERVICES
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). The Contractor is only required
to provide inpatient and outpatient specialty mental health services, as
provided for in this Contract and as required pursuant to section 1396d(r)
of Title 42 of the United States Code, 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 criteria to access SMHS, documented in
accordance with state and federal requirements.
D. The Contractor shall provide or arrange and pay for all medically
necessary covered specialty mental health services in a sufficient amount,
duration, and 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. The Contractor may deny services based on
Welfare and Institutions Code sections 14184.402, subdivisions (a), (c),
and (d), 14059.5; and departmental guidance and regulation. (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. Code-Regs., tit.
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 criteria for access to SMHS, 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).)
County of Fresno
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Exhibit A— Attachment 2
SCOPE OF SERVICES
G. The Contractor shall provide a beneficiary's choice of the person providing
services to the extent feasible in accordance with Cal. Code-Regs., tit. 9,
section 1830.225 and 42 Code of Federal Regulations part 438.3(I).
3. Requirements for Day Treatment Intensive and Day Rehabilitation
A. The Contractor shall require providers to request prior authorization for
day treatment intensive and day rehabilitation services, in accordance with
Information Notice 22-016 and any subsequent departmental notices.
B. The Contractor shall require that providers of day treatment intensive and
day rehabilitation meet the requirements of Cal. Code Regs., tit. 9, §§
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) 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 and 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.
2) Process groups. These groups, facilitated by staff, shall assist
each beneficiary to develop necessary skills to deal with their
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
County of Fresno
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Exhibit A— Attachment 2
SCOPE OF SERVICES
may include psychotherapy instead of process groups, or in
addition to process groups.
3) 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.
4) 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
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.
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.
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Exhibit A— Attachment 2
SCOPE OF SERVICES
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
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 Cal. Code Regs., tit. 9, section 1840.350, for day
treatment intensive, and Cal. Code Regs., 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 the Contractor and the
Department to audit the program if it uses day treatment intensive or day
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Exhibit A— Attachment 2
SCOPE OF SERVICES
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. 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. 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
requirements in BHIN 22-019.
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
the date the provider begins delivering day treatment intensive or day
rehabilitation.
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Exhibit A— Attachment 2
SCOPE OF SERVICES
J. 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 of 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.
4. Therapeutic Behavioral Services
Therapeutic Behavioral Services (TBS) are specialty mental health services
covered as Early and Periodic Screening, Diagnostic and Treatment (EPSDT).
(Cal. Code Regs., 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 is described in the Department of Mental Health Information Notice 08-38.
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Exhibit A— Attachment 3
FINANCIAL REQUIREMENTS
1. Provider Compensation
The Department shall ensure that no payment is made to a network provider
other than by the Contractor for services covered under this agreement, except
when these payments are specifically required to be made by the Department in
Title XIX of the Act, in 42 CFR chapter IV. (42 C.F.R. § 438.60.)
2. Payments for Indian Health Care Providers
A. The Contractor shall make payment to all Indian Health Care Providers
(IHCPs) (42 CFR 438.14(a)) 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 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. The 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).)
C. The Contractor shall comply with guidance issued by DHCS regarding
Payments for Indian Health Care Providers.
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:
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Exhibit A— Attachment 3
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
the Welf. & Inst. Code § 14705(c), unless that date is extended by the
Department, 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
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Exhibit A— Attachment 3
FINANCIAL REQUIREMENTS
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 the 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), 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,
the Department shall invoice the Contractor and the Contractor shall
return the overpayment to the Department.
7. Recovery of Overpayments
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Exhibit A— Attachment 3
FINANCIAL REQUIREMENTS
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 the 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. Contractor shall comply with the reporting
requirements, and other requirements, in BHIN 19-034. (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 between the Contractor and a
subcontractor (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.
2) Specific payment can be made directly or indirectly under a
Physician Incentive Plan to a physician or physician group as an
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Exhibit A— Attachment 3
FINANCIAL REQUIREMENTS
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).)
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.
10. ICD- 10
A. The Contractor shall use the criteria sets in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5), or current edition, as
the clinical tool to make diagnostic determinations.
Once a DSM-5 mental health disorder 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), or current edition. 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).
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Exhibit A— Attachment 4
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).)
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Exhibit A— Attachment 4
MANAGEMENT INFORMATION SYSTEMS
B. 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. MEDSLITE ACCESS
The Contractor shall perform the following:
A. Establish County Behavioral Health MEDSLITE Coordinators (MEDSLITE
Coordinators) to work with DHCS. These MEDSLITE Coordinators are
required to sign and submit an Oath of Confidentiality to DHCS. Only
these designated MEDSLITE Coordinators may initiate requests to add,
delete, or otherwise modify a MEDSLITE user account. These MEDSLITE
Coordinators are responsible for maintaining an active list of the
Contractor's users with MEDSLITE access and collecting a signed
MEDSLITE Oath of Confidentiality from each user. The MEDSLITE
Coordinators are responsible for ensuring users are informed they cannot
share user accounts, that MEDSLITE is to be used for only authorized
purposes, and that all activity is logged. The MEDSLITE Coordinators may
be changed by written notice to DHCS. They should be employees at an
appropriate level in the organization, with sufficient responsibility to carry
out the duties of this position. The MEDSLITE Coordinators will provide,
assign, delete, and track user login identification information for authorized
staff members. They are responsible for ensuring processes are in place
which result in prompt MEDSLITE account deletion requests when the
Contractor's users leave employment or no longer require access due to
change in job duties.
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Exhibit A— Attachment 4
MANAGEMENT INFORMATION SYSTEMS
B. Ensure that information furnished or secured via MEDSLITE shall be used
solely for the purposes described in this Agreement. The information
obtained from MEDSLITE shall be used exclusively to administer the
Medi-Cal program. The Contractor further agrees that information
obtained under this Agreement will not be reproduced, published, sold, or
released in original or any other form for any purpose other than identified
in this Agreement.
C. Ensure that any agents, including a subcontractor, (if prior approval is
obtained from DHCS) to whom they provide DHCS data, agree in writing
to the same requirements for privacy and security safeguards for
confidential data that apply to the Contractor with respect to this
Agreement. The Contractor shall seek prior written approval from DHCS
before providing DHCS data to a subcontractor.
D. Adhere to security and confidential provisions outlined in Exhibit F, the
Privacy and Security Provisions for the protection of any information
exchanged between Contractor Name and the DHCS.
E. During the term of this Agreement, the Contractor agrees to implement
reasonable systems for the discovery and prompt reporting of any breach
or security incident involving DHCS data following the process outlined
within Section 17 of Exhibit F, the Privacy and Security Provisions of this
Agreement.
F. In order to enforce this MEDSLITE ACCESS provision, the Contractor
agrees to assist DHCS in performing compliance assessments. These
assessments may involve compliance review questionnaires, and/or
review of the facilities, systems, books, and records of the Contractor, with
reasonable notice from DHCS. Such reviews shall be scheduled at times
that take into account operational and staffing demands. The Contractor
agrees to promptly remedy all violations of any provision of this
Agreement and certify the same to DHCS in writing, or to enter into a
written Corrective Action Plan with DHCS containing deadlines for
achieving compliance with specific provisions of this Agreement.
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Exhibit A— Attachment 5
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 the 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. The 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:
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Exhibit A— Attachment 5
QUALITY IMPROVEMENT SYSTEM
1) Surveying beneficiary/family satisfaction with the Contractor's
services at least annually;
2) Evaluating beneficiary grievances, appeals and State 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. The Contractor's QAPI Program shall include Performance Improvement
Projects as specified in paragraph 5.
2. Quality Improvement (QI) Work Plan
G. 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, State
Hearings, expedited State 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);
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Exhibit A— Attachment 5
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
document QI Committee meeting minutes regarding decisions and actions
taken.
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Exhibit A— Attachment 5
QUALITY IMPROVEMENT SYSTEM
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 in the planning, design
and execution of the QI Program by the Contractor's practitioners and
providers, beneficiaries who have accessed specialty mental health
services through the Contractor, family members, legal representatives, or
other persons similarly involved with beneficiaries as 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;
7) Incorporating successful interventions into the Contractor's
operations as appropriate; and
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Exhibit A— Attachment 5
QUALITY IMPROVEMENT SYSTEM
8) Reviewing beneficiary grievances, appeals, expedited appeals,
State Hearings, expedited State 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).)
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).)
County of Fresno
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Exhibit A— Attachment 5
QUALITY IMPROVEMENT SYSTEM
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; and
4) They are reviewed and updated periodically as appropriate. (42
C.F.R. § 438.236(b).)
C. The 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. The 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
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Exhibit A— Attachment 6
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. Code Regs., tit. 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 criteria for access to SMHS and for
the purpose of utilization control, provided that the services furnished are
sufficient in amount, duration and 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
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Exhibit A— Attachment 6
UTILIZATION MANAGEMENT PROGRAM
2. Service Authorization
A. Contractor shall implement mechanisms to assure authorization decision
standards are met in accordance with Behavioral Health Information
Notices (BHINs) 22-016 and 22-017, 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 G.
B. The Contractor shall comply with authorization timeframes in accordance
with BHINs 22-016 and 22-017, 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).)
County of Fresno
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Exhibit A— Attachment 6
UTILIZATION MANAGEMENT PROGRAM
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), and documents, 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).
D. 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
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Exhibit A— Attachment 7
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. C, 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 criteria for access to 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 criteria for access to 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 criteria for
access to 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, 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
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Exhibit A— Attachment 7
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. Code
Regs., tit. 9, section 1810.365. (42 C.F.R. § 438.206(b)(5).)
C. The Contractor shall comply with the requirements of Cal. Code Regs., tit.
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, the 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. Foster Children Placed Out-of-County
A. In accordance with Welf. & Inst. Code 14717.1, the Contractor shall be
responsible to authorize, pay, provide or arrange for medically necessary
specialty mental health services for foster children 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 (Mental Health and Substance Use Disorder
County of Fresno
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Exhibit A— Attachment 7
ACCESS AND AVAILABILITY OF SERVICES
(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's 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.
5. Children in Adoption Assistance Program (AAP) and Kinship Guardian
Assistance Payment (Kin-GAP)
A. The Contractor shall provide or arrange for the provision of medically
necessary specialty mental health services to a child in the Adoption
Assistance Program (AAP) residing within their adoptive parents' county of
residence in the Contractor's county. These services are to be provided in
the same way as the Contractor would provide services to any other child
for whom the Contractor's 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 Contractor shall provide or arrange for the provision of medically
necessary specialty mental health services to a child in the Kinship-
Guardian Assistance Program (Kin-GAP) residing within their legal
guardian's county of residence in the Contractor's county. These services
are to be provided in the same way that the Contractor would provide
services to any other child for whom the Contractor county is listed as the
County of Fresno
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Exhibit A— Attachment 7
ACCESS AND AVAILABILITY OF SERVICES
county of responsibility on 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 22-
016 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 22-016 and any applicable Departmental notices
issued after the effective date of this contract, when processing or
submitting authorization requests for children in AAP, or Kin-GAP, living
outside their county of origin.
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 their 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).) The Contractor shall document good-faith efforts to contract with
all IHCPs in the Contractor's county. If the Contractor does not contract with a
IHCP in the Contractor's county, the Contractor must submit a written
explanation to the Department of why it failed to contract with that IHCP, with
supporting documentation as provided for in BHIN 21-023. 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
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Exhibit A— Attachment 8
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
provide physical access, reasonable accommodations, and accessible
County of Fresno
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Exhibit A— Attachment 8
PROVIDER NETWORK
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 21-023 and its enclosures, or in
subsequent guidance issued by the Department. (42 C.F.R. § 438.68(a),
(b)(1)(iii), (3), 438.206(a); Welf. & Inst. Code § 14197.)
D. The Contractor may submit to the Department a request for Alternate
Access Standards. The Department will evaluate requests and grant
appropriate exceptions to the state developed standards, as specified in
BHIN 21-023 and its enclosures, or in subsequent guidance issued by the
Department. (42 C.F.R. § 438.68(a), (d), 438.206(a); Welf. & Inst. Code §
14197).
E. The Contractor shall comply with all network adequacy standards
developed by the Department to implement 42 C.F.R. §§ 438.68, 438.206,
and 438.207, including time and distance standards, timely access,
capacity and composition standards, and other network capacity
requirements, as specified in BHIN 21-023 and its enclosures, or in
subsequent guidance issued by the Department.
4. Timely Access
A. Timely Access. In accordance with 42 C.F.R. § 438.206(c)(1), the
Contractor shall-
1) Meet and require its providers to meet 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 21-023 and its enclosures, or in subsequent,
guidance issued by the Department.
2) Comply with the timeliness standards specified in Cal. Code Regs.,
tit. 9, section 1810.405(c) and Welf. & Inst. Code § 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
County of Fresno
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Exhibit A— Attachment 8
PROVIDER NETWORK
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.
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 21-023 and its enclosures, or in subsequent guidance issued by the
Department. (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 21-023 and its enclosures, or in subsequent guidance
issued by the 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).)
County of Fresno
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Exhibit A— Attachment 8
PROVIDER NETWORK
C. The Contractor shall submit the documentation at the times specified in
BHIN 21-023 and its enclosures, 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 Contractor's
operations that would render the Contractor non-compliant with
standards for network adequacy and capacity including, but not
limited to, the following types of changes:
a) Changes in services;
b) Changes in benefits;
c) Changes in geographic service area;
d) Changes in the composition of or payments to the Contractor's
provider network; or
e) Enrollment of a new population in the Contractor's county. (42
C.F.R. § 438.207(c).);
f) The Contractor is required to notify DHCS by email of one of
the listed changes at MHSDFinalRule@dhcs.ca.gov.
D. The Contractor shall include details regarding the change and the
Contractor's plans to ensure beneficiaries continue to have access to
adequate services and providers.
6. Choice of Provider
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Exhibit A— Attachment 8
PROVIDER NETWORK
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. The 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 their
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;
County of Fresno
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Exhibit A— Attachment 8
PROVIDER NETWORK
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, the 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. The 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).)
8. Provider Certification
A. The Contractor shall comply with Cal. Code Regs., tit. 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.
County of Fresno
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Exhibit A— Attachment 8
PROVIDER NETWORK
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. Code Regs., tit. 9, section 1810.435, 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 Cal. Code Regs., tit. 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
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.
County of Fresno
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Exhibit A— Attachment 8
PROVIDER NETWORK
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,
as described in Cal. Code Regs., tit. 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. Code Regs., tit. 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
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Exhibit A— Attachment 8
PROVIDER NETWORK
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.
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 3 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 3 of this exhibit.
J. On-site review is 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
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Exhibit A— Attachment 8
PROVIDER NETWORK
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).
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.
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Exhibit A— Attachment 8
PROVIDER NETWORK
9. Provider Beneficiary Communications
A. The Contractor shall not prohibit nor otherwise restrict, a licensed,
waivered, or registered professional, as defined in Cal. Code Regs., tit. 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
4) The beneficiary's right to participate in decisions regarding their
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 State 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 Hearing after the
Contractor has made a determination on a beneficiary's appeal,
which is adverse to the beneficiary.
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PROVIDER NETWORK
5) The beneficiary's right to request continuation of benefits that the
Contractor seeks to reduce or terminate during an appeal or State
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 Hearing is pending if the final decision is
adverse to the beneficiary.
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Exhibit A— Attachment 9
DOCUMENTATION REQUIRMENTS
1. Documentation Standards
A. The Contractor shall implement and comply with documentation standards as set
forth in guidance issued by the Department in BHIN 22-019.
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Exhibit A— Attachment 10
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 their 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).)
B. Consistent with the No Wrong Door policies set forth in W&I Code section
14184.402, the Contractor must cover the assessment and any SMHS
provided during the assessment period for any beneficiary seeking care,
even prior to the determination of a diagnosis, even prior to the
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Exhibit A— Attachment 10
COORDINATION AND CONTINUITY OF CARE
determination of whether SMHS access criteria set forth in W&I Code section
14184.402(b)(2) are met, and even if the beneficiary is later determined to
need non-specialty mental health services (NSMHS) and/or SUD services
and is referred to the Medi-Cal Fee For Service delivery system or a
Managed Care Plan for NSMHS or to the County Department responsible for
SUD treatment. Contractor must cover SMHS even if the service was not
included in the client plan, and even if the beneficiary has a co-occurring
mental health condition and SUD.
C. As of the effective date identified by DHCS, the Contractor must use DHCS-
approved standardized screening tools set forth in DHCS guidance
(including standardized screening tools specific for adults and standardized
screening tools specific for children and youth) to ensure beneficiaries
seeking mental health services who are not currently receiving covered
SMHS or NSMHS are referred to the appropriate delivery system for mental
health services, either in the Contractor network or the Managed Care Plan
network, in accordance with the No Wrong Door policies set forth in W&I
Code section 14184.402(h).
D. If a beneficiary eligible for SMHS is also eligible for NSMHS during the
course of receiving covered SMHS, the Contractor shall continue to cover
non-duplicative, Medically Necessary SMHS even if the Member is
simultaneously receiving NSMHS.
i. The Contractor must enter into a Memorandum of Understanding with
any Medi-Cal Managed Care Plan serving the Contractor's
beneficiaries to ensure Medically Necessary NSMHS and SMHS
provided concurrently are coordinated and non-duplicative.
ii. If a beneficiary is receiving covered SMHS and is determined to meet
the criteria for NSMHS covered by Medi-Cal Fee For Service and
Managed Care Plans as defined by W&I Code section 14184.402, the
Contractor must use DHCS-approved standardized transition tools set
forth in DHCS guidance as required when beneficiaries who have
established relationships with contracted mental health providers
experience a change in condition requiring NSMHS. Likewise, if a
beneficiary is receiving NSMHS and is determined to meet the access
criteria for SMHS as defined by W&I Code section 14184.402, the
Contractor must use DHCS-approved standardized transition tools set
forth in DHCS guidance as required when beneficiaries who have
established relationships with NSMHS providers experience a change
in condition requiring SMHS. The Contractor must continue to cover
the provision of medically necessary SMHS provided to a beneficiary
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Exhibit A— Attachment 10
COORDINATION AND CONTINUITY OF CARE
who meets SMHS access criteria who is concurrently receiving
NSMHS when those services are not duplicative and provide
coordination of care with the Managed Care Plan.
iii. The Contractor must develop and implement written policies and
procedures to ensure that beneficiaries meeting criteria for NSMHS, as
indicated by a DHCS-approved standardized transition tool (including
standardized transition tools specific for adults and standardized
transition tools specific for children and youth), are referred to the
Managed Care Plan or a Fee For Service provider offering NSMHS.
Likewise, the Contractor must develop and implement written policies
and procedures to ensure that beneficiaries meeting access criteria for
SMHS and as indicated by a DHCS-approved standardized transition
tools (including standardized transition tools specific for adults and
standardized transition tools specific for children and youth) are
referred by the Managed Care Plan to the Contractor.
E. 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 ensure the components of the MOU
comply with guidance issued by DHCS regarding MOU requirements_. The
MOU shall address how to ensure Medically Necessary NSMHS and
SMHS provided concurrently are coordinated and non-duplicative. 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. Should a conflict arise between the parties to the MOU, the
Contractor shall abide by the requirements in BHIN 21-034._(Cal. Code
Regs., tit. 9, § 1810.370.)
F. 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 (42 C.F.R. § 438.62(b)(1)-(2).)
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Exhibit A— Attachment 11
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). 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.
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.)
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;
3) The information is provided in an electronic form which can be
electronically retained and printed;
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Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
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
established in 42 Code of Federal Regulations part 438.68. (42
C.F.R. § 438.10(e)(2)(viii).)
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Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
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, 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, upon request of the
potential beneficiary or beneficiary at no cost. 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 the 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 the 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 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).)
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Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
2) 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).) The 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/TDY) 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
are available free of charge and how to access these 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 languages 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 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
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Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
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, ancestry,
national origin, ethnic group identification, age, 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:
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Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
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).)
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 State 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;
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Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
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.
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 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 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 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).)
j) 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).)
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Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
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)(xiv).)
1) 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:
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.
Code Regs., tit. 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
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Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
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.
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. (42 C.F.R. §
438.10(h)(1)(vii).)
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INFORMATION REQUIREMENTS
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).)
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. The 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 438.30)(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).)
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INFORMATION REQUIREMENTS
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
has executed an advance directive. (42 C.F.R. §§ 422.128(b)(1)(ii)(F),
438.30).)
E. The Contractor shall educate staff concerning its policies and procedures
on advance directives. (42 C.F.R. §§ 422.128(b)(1)(ii)(H), 438.30).)
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. Code Regs., tit. 9, sections 862 through 868, and 42
C. F. R. § 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 their 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 their 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).)
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INFORMATION REQUIREMENTS
6) Request and receive a copy of their 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.)
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 their 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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BENEFICIARY PROBLEM RESOLUTION
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 State Hearings after the exhaustion of an
appeal or expedited appeal process, including information
that a State 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 any office or facility owned or operated
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BENEFICIARY PROBLEM RESOLUTION
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 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 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-
person by the Contractor, or a network provider of the Contractor,
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BENEFICIARY PROBLEM RESOLUTION
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
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
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
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BENEFICIARY PROBLEM RESOLUTION
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).)
16) The Contractor shall provide the beneficiary and their
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
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BENEFICIARY PROBLEM RESOLUTION
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 their
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
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).)
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BENEFICIARY PROBLEM RESOLUTION
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).)
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
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BENEFICIARY PROBLEM RESOLUTION
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. The Contractor's written
notice of extension shall inform the beneficiary of the right to file a
grievance if they disagree 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 they could not be
contacted. (Cal. Code Regs.,tit. 9, § 1850.206(c).)
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:
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BENEFICIARY PROBLEM RESOLUTION
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 7.2-13.)
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 7.2-13.) 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 7.2-13):
a) The original complaint.
b) The provider's or other accused party's response to the
complaint.
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.
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BENEFICIARY PROBLEM RESOLUTION
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).);
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
demonstrates, 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,
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BENEFICIARY PROBLEM RESOLUTION
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. The Contractor's written notice of
extension shall inform the beneficiary of the right to file a grievance
if they disagree with the Contractor's decision. 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).) 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 their 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 their representative the beneficiary's
case file free of charge and sufficiently in advance of the resolution
timeframe for standard appeal resolutions. 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).)
7) Allow the beneficiary, their 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 their representative, of
the resolution of the appeal in writing in a format and language that, at a
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BENEFICIARY PROBLEM RESOLUTION
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 State
Hearing and the procedure for requesting a State Hearing, if
the beneficiary has not already requested a State 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 State 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 they may be liable for the cost of
any continued benefits if the Contractor's adverse 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:
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BENEFICIARY PROBLEM RESOLUTION
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
extend this timeframe by up to 14 calendar days if the beneficiary
requests an extension, or the Contractor demonstrates, 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
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BENEFICIARY PROBLEM RESOLUTION
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 their 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 their
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 they disagree with the decision.
(42 C.F.R. § 438.410(c)(2); 42 C.F.R. § 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 Hearing
"State Hearing" means the hearing provided by the State to beneficiaries
pursuant to sections 50951 and 50953 of Title 22 of the California Code of
Regulations and section 1810.216.6 of Title 9 of the California Code of
Regulations 1810.216.6:
A. If a beneficiary requests a State Hearing, the Department shall grant the
request. (42 C.F.R. § 431.220(a)(5).) The right to a State Hearing, how to
obtain a hearing, and representation rules at a hearing must be explained
to the beneficiary and provider by the Contractor in its notice of decision or
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BENEFICIARY PROBLEM RESOLUTION
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 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 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 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 Hearing
"Expedited Hearing" means a hearing provided by the State, used when the
Contractor determines, or the beneficiary or the beneficiary's provider certifies
that following the 90 day timeframe for a State Hearing as established in 42
C.F.R. § 431.244(f)(1) would seriously jeopardize the beneficiary's life, health, or
ability to 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 State Hearing. (Cal. Code Regs., tit. 22., § 51014.2-1 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).)
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BENEFICIARY PROBLEM RESOLUTION
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 Hearing is pending, the benefits must be
continued until the beneficiary withdraws the appeal or request for State
Hearing, the beneficiary does not request a State 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
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 Hearing was pending if the final
resolution of the appeal or State 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 Hearing officer reverses a decision
to deny, limit, or delay services. (42 C.F.R. § 438.424(a).)
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BENEFICIARY PROBLEM RESOLUTION
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).)
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).)
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Exhibit A— Attachment 12
BENEFICIARY PROBLEM RESOLUTION
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. Code Regs., tit. 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. Code Regs., tit. 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 the
Contractor payment authorization for a specialty mental health service that
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).)
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BENEFICIARY PROBLEM RESOLUTION
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 criteria for access to SMHS
in Attachment 2, section 1 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).)
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, § 1850.2100).)
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.
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Exhibit A— Attachment 12
BENEFICIARY PROBLEM RESOLUTION
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 criteria to access SMHS,
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).)
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 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 State Hearing
or an expedited State Hearing, including:
a) The method by which a hearing may be obtained; (Cal. Code
Regs., tit. 9, § 1850.212(a)(5)(A).)
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BENEFICIARY PROBLEM RESOLUTION
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 State Hearing is
requested; (Cal. Code Regs., tit. 9, § 1850.212(a)(5)(C).)
and
d) The time limits for requesting a State Hearing or an
expedited State 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
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).)
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BENEFICIARY PROBLEM RESOLUTION
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,
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 their 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
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BENEFICIARY PROBLEM RESOLUTION
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
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 they are
ineligible for further services; (42 C.F.R. § 431.213(c).)
4) The beneficiary's whereabouts are unknown and mail directed to
them 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).)
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BENEFICIARY PROBLEM RESOLUTION
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 nursing facility
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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Exhibit A— Attachment 13
PROGRAM INTEGRITY
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
payment of claims under this Contract, shall implement and maintain a
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PROGRAM INTEGRITY
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).)
4. Fraud Reporting Requirements
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PROGRAM INTEGRITY
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).)
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).)
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Exhibit A— Attachment 13
PROGRAM INTEGRITY
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. §
455.101. For purposes of this disclosure, Contractor
may use the business address for any member of its
Board of Supervisors.
County of Fresno
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Exhibit A— Attachment 13
PROGRAM INTEGRITY
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
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
County of Fresno
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Exhibit A— Attachment 13
PROGRAM INTEGRITY
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, the 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 — the 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.
c) The 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
County of Fresno
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Exhibit A— Attachment 13
PROGRAM INTEGRITY
1) The 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.
County of Fresno
22-20101
Page 1 of 3
Exhibit A— Attachment 14
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
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.)
County of Fresno
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Exhibit A— Attachment 14
REPORTING REQUIREMENTS
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
438.66(c), the Contractor will submit the following to the Department (42
C.F.R. §438.604(b).):
1) Enrollment and disenrollment data;
County of Fresno
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Exhibit A— Attachment 14
REPORTING REQUIREMENTS
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.
B. The Contractor shall cooperate with DHCS to provide and report quality
measures per the 1915(b) Special Terms and Conditions and the
Comprehensive Quality Strategy.
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.
County of Fresno
22-20101
Page 1 of 2
Exhibit A— Attachment 15
PEER SUPPORT SERVICES
MEDI-CAL PEER SUPPORT SERVICES
1. The Contractor has taken the option to implement Medi-Cal Peer Support
Services.
2. The Contractor shall provide, or arrange, and pay for Peer Support Services to
Medi-Cal beneficiaries. Contractor's provision of Peer Support Services shall
conform to the requirements of Supplement 3 to Attachment 3.1-A and
Supplement 3 to Attachment 3.1-B of the California State Plan. Contractor's
provision of Peer Support Services and implementation of a Medi-Cal Peer
Support Specialist Certification Program shall further conform to the applicable
requirements of Behavioral Health Information Notice (BHIN) 21-041 and to the
requirements in any subsequent BHINs issued by the Department pursuant to
Welfare & Institutions Code section § 14045.21.
3. Voluntary Participation and Funding
The Contractor shall fund the nonfederal share of any applicable expenditures,
since the Contractor has opted to implement Peer Support Services and
participate in the Peer Support Specialist Certification Program set forth in Article
1.4 of Chapter 7, Part 3, of Division 9 of the Welfare and Institutions Code. The
Contractor's local share utilized to fund Peer Support Services and the
Contractor's participation in the Peer Support Specialist Certification Program
shall not be considered an increase in costs mandated by the 2011 realignment
legislation.
4. Provision of Peer Support Services
Peer Support Services may be provided face-to-face, by telephone or by
telehealth with the beneficiary or significant support person(s) and may be
provided anywhere in the community.
5. Peer Support Specialists
Contractor shall ensure that Peer Support Services are provided by certified Peer
Support Specialists as established in BHIN 21-041.
6. Behavioral Health Professional and Peer Support Specialist Supervisors
The Contractor shall ensure that Peer Support Specialists provide services under
the direction of a Behavioral Health Professional.
County of Fresno
22-20101
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Exhibit A— Attachment 15
PEER SUPPORT SERVICES
A Behavioral Health Professional must be licensed, waivered, or registered in
accordance with applicable State of California licensure requirements and listed
in the California Medicaid State Plan as a qualified provider of SMHS, DMC-
ODS, or DMC.
Peer Support Specialists may also be supervised by Peer Support Specialist
Supervisors, as established in BHIN 21-041.
7. Practice Guidelines
Counties shall require Peer Support Specialists to adhere to the practice
guidelines developed by the Substance Abuse and Mental Health Services
Administration, What are Peer Recovery Support Services (Center for Substance
Abuse Treatment, What are Peer Recovery Support Services? HHS Publication
No.(SMA) 09-4454. Rockville, MD: Substance Abuse and Mental Health Services
Administration, U.S. Department of Health and Human Services), which may be
accessed electronically through the following Internet World Wide Web
connection: www.samhsa.gov/resource/ebp/what-are-peer-recovery-support-
services.
8. Contractor shall oversee and enforce the certification standards and
requirements set forth in Article 1.4 of Chapter 7, Part 3, of Division 9 of the
Welfare and Institutions Code and departmental guidance, including BHIN 21-
041. Contractor shall ensure that the Medi-Cal Peer Support Specialist
Certification Program:
a. Submits to the department a peer support specialist program plan in
accordance with Enclosure 2 of BHIN 21-041 describing how the peer
support specialist program will meet all of the federal and state
requirements for the certification and oversight of peer support specialists.
b. Participates in periodic reviews conducted by the department to ensure
adherence to all federal and state requirements.
c. Submits annual peer support specialist program reports to the department
in accordance with Enclosure 5 of BHIN 21-041. Reports shall cover the
fiscal year and shall be submitted by the following December 31 st
County of Fresno
22-20101
Page 1 of 6
Exhibit B
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
The Contractor and the 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
County of Fresno
22-20101
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Exhibit B
BUDGET DETAIL AND PAYMENT PROVISIONS
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.
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 County Behavioral Health
Director's Association of California, 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.
County of Fresno
22-20101
Page 3 of 6
Exhibit B
BUDGET DETAIL AND PAYMENT PROVISIONS
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)). 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
County of Fresno
22-20101
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Exhibit B
BUDGET DETAIL AND PAYMENT PROVISIONS
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 their 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 their 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 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
County of Fresno
22-20101
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Exhibit B
BUDGET DETAIL AND PAYMENT PROVISIONS
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
The 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 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
County of Fresno
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Exhibit B
BUDGET DETAIL AND PAYMENT PROVISIONS
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.
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
Special Terms and Conditions
(For federally funded service contracts or agreements and grant agreements)
The use of headings or titles throughout this exhibit is for convenience only and shall not
be used to interpret or to govern the meaning of any specific term or condition.
The terms "contract", "Contractor" and "Subcontractor" shall also mean, "agreement",
"grant", "grant agreement", "Grantee" and "Subgrantee" respectively.
The terms "California Department of Health Care Services", "California Department of
Health Services", `Department of Health Care Services", "Department of Health Services",
"CDHCS", "DHCS", "CDHS", and "DHS" shall all have the same meaning and refer to the
California State agency that is a party to this Agreement.
This exhibit contains provisions that require strict adherence to various contracting laws
and policies. Some provisions herein are conditional and only apply if specified conditions
exist(i.e., agreement total exceeds a certain amount; agreement is federally funded, etc.).
The provisions herein apply to this Agreement unless the provisions are removed by
reference on the face of this Agreement, the provisions are superseded by an alternate
provision appearing elsewhere in this Agreement, or the applicable conditions do not
exist.
Revised 08/2021 Page 1 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
Index of Special Terms and Conditions
1. Federal Equal Employment Opportunity 20. Debarment and Suspension
Requirements Certification
2. Travel and Per Diem Reimbursement 21. Smoke-Free Workplace
3. Procurement Rules Certification
4. Equipment Ownership / Inventory / 22. Covenant Against Contingent
Disposition Fees
5. Subcontract Requirements 23. Payment Withholds
6. Income Restrictions 24. Performance Evaluation
7. Audit and Record Retention 25. Officials Not to Benefit
8. Site Inspection 26. Four-Digit Date Compliance
9. Federal Contract Funds 27. Prohibited Use of State Funds
for Software
10. Termination 28. Use of Small, Minority Owned
11. Intellectual Property Rights and Women's Businesses
12. Air or Water Pollution Requirements 29. Alien Ineligibility Certification
13. Prior Approval of Training Seminars, 30. Union Organizing
Workshops or Conferences
31. Contract Uniformity (Fringe
14. Confidentiality of Information Benefit Allowability)
15. Documents, Publications, and Written 32. Suspension or Stop Work
Reports Notification
16. Dispute Resolution Process 33. Public Communications
17. Financial and Compliance Audit 34. Compliance with Statutes and
Requirements Regulations
18. Human Subjects Use Requirements 35. Lobbying Restrictions and
19. Novation Requirements Disclosure Certification
Revised 08/2021 Page 2 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
1. Federal Equal Opportunity Requirements
(Applicable to all federally funded agreements entered into by the Department of
Health Care Services)
a. The Contractor will not discriminate against any employee or applicant for
employment because of race, color, religion, sex, national origin, physical or
mental handicap, disability, age or status as a disabled veteran or veteran of the
Vietnam era. The Contractor will take affirmative action to ensure that qualified
applicants are employed, and that employees are treated during employment,
without regard to their race, color, religion, sex, national origin, physical or mental
handicap, disability, age or status as a disabled veteran or veteran of the
Vietnam era. Such action shall include, but not be limited to the following:
employment, upgrading, demotion or transfer; recruitment or recruitment
advertising; layoff or termination; rates of pay or other forms of compensation;
and career development opportunities and selection for training, including
apprenticeship. The Contractor agrees to post in conspicuous places, available
to employees and applicants for employment, notices to be provided by the
Federal Government or DHCS, setting forth the provisions of the Equal
Opportunity clause, Section 503 of the Rehabilitation Act of 1973 and the
affirmative action clause required by the Vietnam Era Veterans' Readjustment
Assistance Act of 1974 (38 U.S.C. 4212). Such notices shall state the
Contractor's obligation under the law to take affirmative action to employ and
advance in employment qualified applicants without discrimination based on their
race, color, religion, sex, national origin physical or mental handicap, disability,
age or status as a disabled veteran or veteran of the Vietnam era and the rights
of applicants and employees.
b. The Contractor will, in all solicitations or advancements for employees placed by
or on behalf of the Contractor, state that all qualified applicants will receive
consideration for employment without regard to race, color, religion, sex, national
origin physical or mental handicap, disability, age or status as a disabled veteran
or veteran of the Vietnam era.
c. The Contractor will send to each labor union or representative of workers with
which it has a collective bargaining agreement or other contract or understanding
a notice, to be provided by the Federal Government or the State, advising the
labor union or workers' representative of the Contractor's commitments under the
provisions herein and shall post copies of the notice in conspicuous places
available to employees and applicants for employment.
d. The Contractor will comply with all provisions of and furnish all information and
reports required by Section 503 of the Rehabilitation Act of 1973, as amended,
the Vietnam Era Veterans' Readjustment Assistance Act of 1974 (38 U.S.C.
4212) and of the Federal Executive Order No. 11246 as amended, including by
Executive Order 11375, `Amending Executive Order 11246 Relating to Equal
Employment Opportunity,' and as supplemented by regulation at 41 CFR part 60,
"Office of the Federal Contract Compliance Programs, Equal Employment
Opportunity, Department of Labor," and of the rules, regulations, and relevant
orders of the Secretary of Labor.
Revised 08/2021 Page 3 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
e. The Contractor will furnish all information and reports required by Federal
Executive Order No. 11246 as amended, including by Executive Order 11375,
'Amending Executive Order 11246 Relating to Equal Employment Opportunity,`
and as supplemented by regulation at 41 CFR part 60, "Office of Federal
Contract Compliance Programs, Equal Employment Opportunity, Department of
Labor," and the Rehabilitation Act of 1973, and by the rules, regulations, and
orders of the Secretary of Labor, or pursuant thereto, and will permit access to its
books, records, and accounts by the State and its designated representatives
and the Secretary of Labor for purposes of investigation to ascertain compliance
with such rules, regulations, and orders.
f. In the event of the Contractor's noncompliance with the requirements of the
provisions herein or with any federal rules, regulations, or orders which are
referenced herein, this Agreement may be cancelled, terminated, or suspended
in whole or in part and the Contractor may be declared ineligible for further
federal and state contracts in accordance with procedures authorized in Federal
Executive Order No. 11246 as amended and such other sanctions may be
imposed and remedies invoked as provided in Federal Executive Order No.
11246 as amended, including by Executive Order 11375, `Amending Executive
Order 11246 Relating to Equal Employment Opportunity,` and as supplemented
by regulation at 41 CFR part 60, "Office of Federal Contract Compliance
Programs, Equal Employment Opportunity, Department of Labor," or by rule,
regulation, or order of the Secretary of Labor, or as otherwise provided by law.
g. The Contractor will include the provisions of Paragraphs a through g in every
subcontract or purchase order unless exempted by rules, regulations, or orders
of the Secretary of Labor issued pursuant to Federal Executive Order No. 11246
as amended, including by Executive Order 11375, 'Amending Executive Order
11246 Relating to Equal Employment Opportunity,' and as supplemented by
regulation at 41 CFR part 60, "Office of Federal Contract Compliance Programs,
Equal Employment Opportunity, Department of Labor," or Section 503 of the
Rehabilitation Act of 1973 or (38 U.S.C. 4212) of the Vietnam Era Veteran's
Readjustment Assistance Act, so that such provisions will be binding upon each
subcontractor or vendor. The Contractor will take such action with respect to any
subcontract or purchase order as the Director of the Office of Federal Contract
Compliance Programs or DHCS may direct as a means of enforcing such
provisions including sanctions for noncompliance provided, however, that in the
event the Contractor becomes involved in, or is threatened with litigation by a
subcontractor or vendor as a result of such direction by DHCS, the Contractor
may request in writing to DHCS, who, in turn, may request the United States to
enter into such litigation to protect the interests of the State and of the United
States.
2. Travel and Per Diem Reimbursement
(Applicable if travel and/or per diem expenses are reimbursed with agreement
funds.)
Reimbursement for travel and per diem expenses from DHCS under this Agreement
shall, unless otherwise specified in this Agreement, be at the rates currently in effect,
Revised 08/2021 Page 4 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
as established by the California Department of Human Resources (CaIHR), for
nonrepresented state employees as stipulated in DHCS' Travel Reimbursement
Information Exhibit. If the CaIHR rates change during the term of the Agreement, the
new rates shall apply upon their effective date and no amendment to this Agreement
shall be necessary. Exceptions to CaIHR rates may be approved by DHCS upon the
submission of a statement by the Contractor indicating that such rates are not
available to the Contractor. No travel outside the State of California shall be
reimbursed without prior authorization from DHCS. Verbal authorization should be
confirmed in writing. Written authorization may be in a form including fax or email
confirmation.
3. Procurement Rules
(Applicable to agreements in which equipment/property, commodities and/or
supplies are furnished by DHCS or expenses for said items are reimbursed by
DHCS with state or federal funds provided under the Agreement.)
a. Equipment/Property definitions
Wherever the term equipment and/or property is used, the following definitions
shall apply:
(1) Major equipment/property: A tangible or intangible item having a base unit
cost of$5,000 or more with a life expectancy of one (1) year or more and is
either furnished by DHCS or the cost is reimbursed through this Agreement.
Software and videos are examples of intangible items that meet this
definition.
(2) Minor equipment/property: A tangible item having a base unit cost of less
than $5,000 with a life expectancy of one (1) year or more and is either
furnished by DHCS or the cost is reimbursed through this Agreement.
b. Government and public entities (including state colleges/universities and
auxiliary organizations), whether acting as a contractor and/or subcontractor,
may secure all commodities, supplies, equipment and services related to such
purchases that are required in performance of this Agreement. Said
procurements are subject to Paragraphs d through h of Provision 3. Paragraph c
of Provision 3 shall also apply, if equipment/property purchases are delegated to
subcontractors that are nonprofit organizations or commercial businesses.
c. Nonprofit organizations and commercial businesses, whether acting as a
contractor and/or subcontractor, may secure commodities, supplies,
equipment/property and services related to such purchases for performance
under this Agreement.
(1) Equipment/property purchases shall not exceed $50,000 annually.
To secure equipment/property above the annual maximum limit of$50,000,
the Contractor shall make arrangements through the appropriate DHCS
Program Contract Manager, to have all remaining equipment/property
purchased through DHCS' Purchasing Unit. The cost of equipment/property
Revised 08/2021 Page 5 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
purchased by or through DHCS shall be deducted from the funds available in
this Agreement. Contractor shall submit to the DHCS Program Contract
Manager a list of equipment/property specifications for those items that the
State must procure. DHCS may pay the vendor directly for such arranged
equipment/property purchases and title to the equipment/property will remain
with DHCS. The equipment/property will be delivered to the Contractor's
address, as stated on the face of the Agreement, unless the Contractor
notifies the DHCS Program Contract Manager, in writing, of an alternate
delivery address.
(2) All equipment/property purchases are subject to Paragraphs d through h of
Provision 3. Paragraph b of Provision 3 shall also apply, if equipment/property
purchases are delegated to subcontractors that are either a government or
public entity.
(3) Nonprofit organizations and commercial businesses shall use a procurement
system that meets the following standards:
(a) Maintain a code or standard of conduct that shall govern the performance
of its officers, employees, or agents engaged in awarding procurement
contracts. No employee, officer, or agent shall participate in the selection,
award, or administration of a procurement, or bid contract in which, to his
or her knowledge, he or she has a financial interest.
(b) Procurements shall be conducted in a manner that provides, to the
maximum extent practical, open, and free competition.
(c) Procurements shall be conducted in a manner that provides for all of the
following:
[1] Avoid purchasing unnecessary or duplicate items.
[2] Equipment/property solicitations shall be based upon a clear and
accurate description of the technical requirements of the goods to be
procured.
[3] Take positive steps to utilize small and veteran owned businesses.
d. Unless waived or otherwise stipulated in writing by DHCS, prior written
authorization from the appropriate DHCS Program Contract Manager will be
required before the Contractor will be reimbursed for any purchase of $5,000 or
more for commodities, supplies, equipment/property, and services related to
such purchases. The Contractor must provide in its request for authorization all
particulars necessary, as specified by DHCS, for evaluating the necessity or
desirability of incurring such costs. The term "purchase" excludes the purchase
of services from a subcontractor and public utility services at rates established for
uniform applicability to the general public.
e. In special circumstances, determined by DHCS (e.g., when DHCS has a need to
monitor certain purchases, etc.), DHCS may require prior written authorization
and/or the submission of paid vendor receipts for any purchase, regardless of
Revised 08/2021 Page 6 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
dollar amount. DHCS reserves the right to either deny claims for reimbursement
or to request repayment for any Contractor and/or subcontractor purchase that
DHCS determines to be unnecessary in carrying out performance under this
Agreement.
f. The Contractor and/or subcontractor must maintain a copy or narrative
description of the procurement system, guidelines, rules, or regulations that will
be used to make purchases under this Agreement. The State reserves the right
to request a copy of these documents and to inspect the purchasing practices of
the Contractor and/or subcontractor at any time.
g. For all purchases, the Contractor and/or subcontractor must maintain copies of
all paid vendor invoices, documents, bids and other information used in vendor
selection, for inspection or audit. Justifications supporting the absence of bidding
(i.e., sole source purchases) shall also be maintained on file by the Contractor
and/or subcontractor for inspection or audit.
h. DHCS may, with cause (e.g., with reasonable suspicion of unnecessary
purchases or use of inappropriate purchase practices, etc.), withhold, cancel,
modify, or retract the delegated purchase authority granted under Paragraphs b
and/or c of Provision 3 by giving the Contractor no less than 30 calendar days
written notice.
4. Equipment/Property Ownership / Inventory / Disposition
(Applicable to agreements in which equipment/property is furnished by DHCS and/or
when said items are purchased or reimbursed by DHCS with state or federal funds
provided under the Agreement.)
a. Wherever the term equipment and/or property is used in Provision 4, the
definitions in Paragraph a of Provision 3 shall apply.
Unless otherwise stipulated in this Agreement, all equipment and/or property that
is purchased/reimbursed with agreement funds or furnished by DHCS under the
terms of this Agreement shall be considered state equipment and the property of
DHCS.
(1) Reporting of Equipment/Property Receipt
DHCS requires the reporting, tagging and annual inventorying of all
equipment and/or property that is furnished by DHCS or
purchased/reimbursed with funds provided through this Agreement.
Upon receipt of equipment and/or property, the Contractor shall report the
receipt to the DHCS Program Contract Manager. To report the receipt of said
items and to receive property tags, Contractor shall use a form or format
designated by DHCS' Asset Management Unit. If the appropriate form (i.e.,
Contractor Equipment Purchased with DHCS Funds) does not accompany
this Agreement, Contractor shall request a copy from the DHCS Program
Contract Manager.
Revised 08/2021 Page 7 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
(2) Annual Equipment/Property Inventory
If the Contractor enters into an agreement with a term of more than twelve
months, the Contractor shall submit an annual inventory of state equipment
and/or property to the DHCS Program Contract Manager using a form or
format designated by DHCS' Asset Management Unit. If an inventory report
form (i.e., Inventory/Disposition of DHCS-Funded Equipment) does not
accompany this Agreement, Contractor shall request a copy from the DHCS
Program Contract Manager. Contractor shall:
(a) Include in the inventory report, equipment and/or property in the
Contractor's possession and/or in the possession of a subcontractor
(including independent consultants).
(b) Submit the inventory report to DHCS according to the instructions
appearing on the inventory form or issued by the DHCS Program Contract
Manager.
(c) Contact the DHCS Program Contract Manager to learn how to remove,
trade-in, sell, transfer or survey off, from the inventory report, expired
equipment and/or property that is no longer wanted, usable or has passed
its life expectancy. Instructions will be supplied by either the DHCS
Program Contract Manager or DHCS' Asset Management Unit.
b. Title to state equipment and/or property shall not be affected by its incorporation
or attachment to any property not owned by the State.
c. Unless otherwise stipulated, DHCS shall be under no obligation to pay the cost of
restoration, or rehabilitation of the Contractor's and/or Subcontractor's facility
which may be affected by the removal of any state equipment and/or property.
d. The Contractor and/or Subcontractor shall maintain and administer a sound
business program for ensuring the proper use, maintenance, repair, protection,
insurance and preservation of state equipment and/or property.
(1) In administering this provision, DHCS may require the Contractor and/or
Subcontractor to repair or replace, to DHCS' satisfaction, any damaged, lost
or stolen state equipment and/or property. In the event of state equipment
and/or miscellaneous property theft, Contractor and/or Subcontractor shall
immediately file a theft report with the appropriate police agency or the
California Highway Patrol and Contractor shall promptly submit one copy of
the theft report to the DHCS Program Contract Manager.
e. Unless otherwise stipulated by the Program funding this Agreement, equipment
and/or property purchased/reimbursed with agreement funds or furnished by
DHCS under the terms of this Agreement, shall only be used for performance of
this Agreement or another DHCS agreement.
f. Within sixty (60) calendar days prior to the termination or end of this Agreement,
the Contractor shall provide a final inventory report of equipment and/or property
to the DHCS Program Contract Manager and shall, at that time, query DHCS as
Revised 08/2021 Page 8 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
to the requirements, including the manner and method, of returning state
equipment and/or property to DHCS. Final disposition of equipment and/or
property shall be at DHCS expense and according to DHCS instructions.
Equipment and/or property disposition instructions shall be issued by DHCS
immediately after receipt of the final inventory report. At the termination or
conclusion of this Agreement, DHCS may at its discretion, authorize the
continued use of state equipment and/or property for performance of work under
a different DHCS agreement.
g. Motor Vehicles
(Applicable only if motor vehicles are purchased/reimbursed with agreement
funds or furnished by DHCS under this Agreement.)
(1) If motor vehicles are purchased/reimbursed with agreement funds or
furnished by DHCS under the terms of this Agreement, within thirty (30)
calendar days prior to the termination or end of this Agreement, the
Contractor and/or Subcontractor shall return such vehicles to DHCS and shall
deliver all necessary documents of title or registration to enable the proper
transfer of a marketable title to DHCS.
(2) If motor vehicles are purchased/reimbursed with agreement funds or
furnished by DHCS under the terms of this Agreement, the State of California
shall be the legal owner of said motor vehicles and the Contractor shall be the
registered owner. The Contractor and/or a subcontractor may only use said
vehicles for performance and under the terms of this Agreement.
(3) The Contractor and/or Subcontractor agree that all operators of motor
vehicles, purchased/reimbursed with agreement funds or furnished by DHCS
under the terms of this Agreement, shall hold a valid State of California
driver's license. In the event that ten or more passengers are to be
transported in any one vehicle, the operator shall also hold a State of
California Class B driver's license.
(4) If any motor vehicle is purchased/reimbursed with agreement funds or
furnished by DHCS under the terms of this Agreement, the Contractor and/or
Subcontractor, as applicable, shall provide, maintain, and certify that, at a
minimum, the following type and amount of automobile liability insurance is in
effect during the term of this Agreement or any extension period during which
any vehicle remains in the Contractor's and/or Subcontractor's possession:
Automobile Liability Insurance
(a) The Contractor, by signing this Agreement, hereby certifies that it
possesses or will obtain automobile liability insurance in the amount of
$1,000,000 per occurrence for bodily injury and property damage
combined. Said insurance must be obtained and made effective upon the
delivery date of any motor vehicle, purchased/reimbursed with agreement
funds or furnished by DHCS under the terms of this Agreement, to the
Contractor and/or Subcontractor.
Revised 08/2021 Page 9 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
(b) The Contractor and/or Subcontractor shall, as soon as practical, furnish a
copy of the certificate of insurance to the DHCS Program Contract
Manager. The certificate of insurance shall identify the DHCS contract or
agreement number for which the insurance applies.
(c) The Contractor and/or Subcontractor agree that bodily injury and property
damage liability insurance, as required herein, shall remain in effect at all
times during the term of this Agreement or until such time as the motor
vehicle is returned to DHCS.
(d) The Contractor and/or Subcontractor agree to provide, at least thirty (30)
days prior to the expiration date of said insurance coverage, a copy of a
new certificate of insurance evidencing continued coverage, as indicated
herein, for not less than the remainder of the term of this Agreement, the
term of any extension or continuation thereof, or for a period of not less
than one (1) year.
(e) The Contractor and/or Subcontractor, if not a self-insured government
and/or public entity, must provide evidence, that any required certificates
of insurance contain the following provisions:
[1] The insurer will not cancel the insured's coverage without giving thirty
(30) calendar days prior written notice to the State (California
Department of Health Care Services).
[2] The State of California, its officers, agents, employees, and servants
are included as additional insureds, but only with respect to work
performed for the State under this Agreement and any extension or
continuation of this Agreement.
[3] The insurance carrier shall notify the California Department of Health
Care Services (DHCS), in writing, of the Contractor's failure to pay
premiums; its cancellation of such policies; or any other substantial
change, including, but not limited to, the status, coverage, or scope of
the required insurance. Such notices shall contain a reference to each
agreement number for which the insurance was obtained.
(f) The Contractor and/or Subcontractor is hereby advised that copies of
certificates of insurance may be subject to review and approval by the
Department of General Services (DGS), Office of Risk and Insurance
Management. The Contractor shall be notified by DHCS, in writing, if this
provision is applicable to this Agreement. If DGS approval of the certificate
of insurance is required, the Contractor agrees that no work or services
shall be performed prior to obtaining said approval.
(g) In the event the Contractor and/or Subcontractor fails to keep insurance
coverage, as required herein, in effect at all times during vehicle
possession, DHCS may, in addition to any other remedies it may have,
terminate this Agreement upon the occurrence of such event.
Revised 08/2021 Page 10 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
5. Subcontract Requirements
(Applicable to agreements under which services are to be performed by
subcontractors including independent consultants.)
a. Prior written authorization will be required before the Contractor enters into or is
reimbursed for any subcontract for services costing $5,000 or more. Except as
indicated in Paragraph a(3) herein, when securing subcontracts for services
exceeding $5,000, the Contractor shall obtain at least three bids or justify a sole
source award.
(1) The Contractor must provide in its request for authorization, all information
necessary for evaluating the necessity or desirability of incurring such cost.
(2) DHCS may identify the information needed to fulfill this requirement.
(3) Subcontracts performed by the following entities or for the service types listed
below are exempt from the bidding and sole source justification requirements:
(a) A local governmental entity or the federal government,
(b) A State college or State university from any State,
(c) A Joint Powers Authority,
(d) An auxiliary organization of a California State University or a California
community college,
(e) A foundation organized to support the Board of Governors of the California
Community Colleges,
(f) An auxiliary organization of the Student Aid Commission established
under Education Code § 69522,
(g) Firms or individuals proposed for use and approved by DHCS' funding
Program via acceptance of an application or proposal for funding or
pre/post contract award negotiations,
(h) Entities and/or service types identified as exempt from advertising and
competitive bidding in State Contracting Manual Chapter 5 Section 5.80
Subsection B.2.
b. DHCS reserves the right to approve or disapprove the selection of
subcontractors and with advance written notice, require the substitution of
subcontractors and require the Contractor to terminate subcontracts entered into
in support of this Agreement.
(1) Upon receipt of a written notice from DHCS requiring the substitution and/or
termination of a subcontract, the Contractor shall take steps to ensure the
completion of any work in progress and select a replacement, if applicable,
within 30 calendar days, unless a longer period is agreed to by DHCS.
Revised 08/2021 Page 11 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
c. Actual subcontracts (i.e., written agreement between the Contractor and a
subcontractor) of $5,000 or more are subject to the prior review and written
approval of DHCS. DHCS may, at its discretion, elect to waive this right. All such
waivers shall be confirmed in writing by DHCS.
d. Contractor shall maintain a copy of each subcontract entered into in support of
this Agreement and shall, upon request by DHCS, make copies available for
approval, inspection, or audit.
e. DHCS assumes no responsibility for the payment of subcontractors used in the
performance of this Agreement. Contractor accepts sole responsibility for the
payment of subcontractors used in the performance of this Agreement.
f. The Contractor is responsible for all performance requirements under this
Agreement even though performance may be carried out through a subcontract.
g. The Contractor shall ensure that all subcontracts for services include provision(s)
requiring compliance with applicable terms and conditions specified in this
Agreement.
h. The Contractor agrees to include the following clause, relevant to record
retention, in all subcontracts for services:
"(Subcontractor Name) agrees to maintain and preserve, until three years after
termination of (Agreement Number) and final payment from DHCS to the
Contractor, to permit DHCS or any duly authorized representative, to have
access to, examine or audit any pertinent books, documents, papers and records
related to this subcontract and to allow interviews of any employees who might
reasonably have information related to such records."
i. Unless otherwise stipulated in writing by DHCS, the Contractor shall be the
subcontractor's sole point of contact for all matters related to performance and
payment under this Agreement.
j. Contractor shall, as applicable, advise all subcontractors of their obligations
pursuant to the following numbered provisions of this Exhibit: 1, 2, 3, 4, 5, 6, 7, 8,
10, 11, 12, 13, 14, 17, 19, 20, 24, 32 and/or other numbered provisions herein
that are deemed applicable.
6. Income Restrictions
Unless otherwise stipulated in this Agreement, the Contractor agrees that any
refunds, rebates, credits, or other amounts (including any interest thereon) accruing
to or received by the Contractor under this Agreement shall be paid by the
Contractor to DHCS, to the extent that they are properly allocable to costs for which
the Contractor has been reimbursed by DHCS under this Agreement.
Revised 08/2021 Page 12 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
7. Audit and Record Retention
(Applicable to agreements in excess of$10,000.)
a. The Contractor and/or Subcontractor shall maintain books, records, documents,
and other evidence, accounting procedures and practices, sufficient to properly
reflect all direct and indirect costs of whatever nature claimed to have been
incurred in the performance of this Agreement, including any matching costs and
expenses. The foregoing constitutes "records" for the purpose of this provision.
b. The Contractor's and/or subcontractor's facility or office or such part thereof as
may be engaged in the performance of this Agreement and his/her records shall
be subject at all reasonable times to inspection, audit, and reproduction.
c. Contractor agrees that DHCS, the Department of General Services, the Bureau
of State Audits, or their designated representatives including the Comptroller
General of the United States shall have the right to review and to copy any
records and supporting documentation pertaining to the performance of this
Agreement. Contractor agrees to allow the auditor(s) access to such records
during normal business hours and to allow interviews of any employees who
might reasonably have information related to such records. Further, the
Contractor agrees to include a similar right of the State to audit records and
interview staff in any subcontract related to performance of this Agreement. (GC
8546.7, CCR Title 2, Section 1896.77)
d. The Contractor and/or Subcontractor shall preserve and make available his/her
records (1) for a period of three years from the date of final payment under this
Agreement, and (2) for such longer period, if any, as is required by applicable
statute, by any other provision of this Agreement, or by subparagraphs (1) or (2)
below.
(1) If this Agreement is completely or partially terminated, the records relating to
the work terminated shall be preserved and made available for a period of
three years from the date of any resulting final settlement.
(2) If any litigation, claim, negotiation, audit, or other action involving the records
has been started before the expiration of the three-year period, the records
shall be retained until completion of the action and resolution of all issues
which arise from it, or until the end of the regular three-year period, whichever
is later.
e. The Contractor and/or Subcontractor may, at its discretion, following receipt of
final payment under this Agreement, reduce its accounts, books and records
related to this Agreement to microfilm, computer disk, CD ROM, DVD, or other
data storage medium. Upon request by an authorized representative to inspect,
audit or obtain copies of said records, the Contractor and/or Subcontractor must
supply or make available applicable devices, hardware, and/or software
necessary to view, copy and/or print said records. Applicable devices may
include, but are not limited to, microfilm readers and microfilm printers, etc.
Revised 08/2021 Page 13 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
f. The Contractor shall, if applicable, comply with the Single Audit Act and the audit
requirements set forth in 2 C.F.R. § 200.501 (2014).
8. Site Inspection
The State, through any authorized representatives, has the right at all reasonable
times to inspect or otherwise evaluate the work performed or being performed
hereunder including subcontract supported activities and the premises in which it is
being performed. If any inspection or evaluation is made of the premises of the
Contractor or Subcontractor, the Contractor shall provide and shall require
Subcontractors to provide all reasonable facilities and assistance for the safety and
convenience of the authorized representatives in the performance of their duties. All
inspections and evaluations shall be performed in such a manner as will not unduly
delay the work.
9. Federal Contract Funds
(Applicable only to that portion of an agreement funded in part or whole with federal
funds.)
a. It is mutually understood between the parties that this Agreement may have been
written before ascertaining the availability of congressional appropriation of
funds, for the mutual benefit of both parties, in order to avoid program and fiscal
delays which would occur if the Agreement were executed after that
determination was made.
b. This agreement is valid and enforceable only if sufficient funds are made
available to the State by the United States Government for the fiscal years
covered by the term of this Agreement. In addition, this Agreement is subject to
any additional restrictions, limitations, or conditions enacted by the Congress or
any statute enacted by the Congress which may affect the provisions, terms or
funding of this Agreement in any manner.
c. It is mutually agreed that if the Congress does not appropriate sufficient funds for
the program, this Agreement shall be amended to reflect any reduction in funds.
d. DHCS has the option to invalidate or cancel the Agreement with 30-days
advance written notice or to amend the Agreement to reflect any reduction in
funds.
10.Termination
a. For Cause
The State may terminate this Agreement, in whole or in part, and be relieved of
any payments should the Contractor fail to perform the requirements of this
Agreement at the time and in the manner herein provided. In the event of such
termination, the State may proceed with the work in any manner deemed proper
by the State. All costs to the State shall be deducted from any sum due the
Contractor under this Agreement and the balance, if any, shall be paid to the
Contractor upon demand. If this Agreement is terminated, in whole or in part, the
Revised 08/2021 Page 14 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
State may require the Contractor to transfer title, or in the case of licensed
software, license, and deliver to the State any completed deliverables, partially
completed deliverables, and any other materials, related to the terminated portion
of the Contract, including but not limited to, computer programs, data files, user
and operations manuals, system and program documentation, training programs
related to the operation and maintenance of the system, and all information
necessary for the reimbursement of any outstanding Medicaid claims. The State
shall pay contract price for completed deliverables delivered and accepted and
items the State requires the Contractor to transfer as described in this paragraph
above.
b. For Convenience
The State retains the option to terminate this Agreement, in whole or in part,
without cause, at the State's convenience, without penalty, provided that written
notice has been delivered to the Contractor at least ninety (90) calendar days
prior to such termination date. In the event of termination, in whole or in part,
under this paragraph, the State may require the Contractor to transfer title, or in
the case of licensed software, license, and deliver to the State any completed
deliverables, partially completed deliverables, and any other materials related to
the terminated portion of the contract including but not limited to, computer
programs, data files, user and operations manuals, system and program
documentation, training programs related to the operation and maintenance of
the system, and all information necessary for the reimbursement of any
outstanding Medicaid claims. The Contractor will be entitled to compensation
upon submission of an invoice and proper proof of claim for the services and
products satisfactorily rendered, subject to all payment provisions of the
Agreement. Payment is limited to expenses necessarily incurred pursuant to this
Agreement up to the date of termination.
11.Intellectual Property Rights
a. Ownership
(1) Except where DHCS has agreed in a signed writing to accept a license,
DHCS shall be and remain, without additional compensation, the sole owner
of any and all rights, title and interest in all Intellectual Property, from the
moment of creation, whether or not jointly conceived, that are made,
conceived, derived from, or reduced to practice by Contractor or DHCS and
which result directly or indirectly from this Agreement.
(2) For the purposes of this Agreement, Intellectual Property means recognized
protectable rights and interest such as: patents, (whether or not issued)
copyrights, trademarks, service marks, applications for any of the foregoing,
inventions, trade secrets, trade dress, logos, insignia, color combinations,
slogans, moral rights, right of publicity, author's rights, contract and licensing
rights, works, mask works, industrial design rights, rights of priority, know
how, design flows, methodologies, devices, business processes,
developments, innovations, good will and all other legal rights protecting
intangible proprietary information as may exist now and/or here after come
Revised 08/2021 Page 15 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
into existence, and all renewals and extensions, regardless of whether those
rights arise under the laws of the United States, or any other state, country or
jurisdiction.
(a) For the purposes of the definition of Intellectual Property, "works" means
all literary works, writings and printed matter including the medium by
which they are recorded or reproduced, photographs, art work, pictorial
and graphic representations and works of a similar nature, film, motion
pictures, digital images, animation cells, and other audiovisual works
including positives and negatives thereof, sound recordings, tapes,
educational materials, interactive videos and any other materials or
products created, produced, conceptualized and fixed in a tangible
medium of expression. It includes preliminary and final products and any
materials and information developed for the purposes of producing those
final products. Works does not include articles submitted to peer review or
reference journals or independent research projects.
(3) In the performance of this Agreement, Contractor will exercise and utilize
certain of its Intellectual Property in existence prior to the effective date of this
Agreement. In addition, under this Agreement, Contractor may access and
utilize certain of DHCS' Intellectual Property in existence prior to the effective
date of this Agreement. Except as otherwise set forth herein, Contractor shall
not use any of DHCS' Intellectual Property now existing or hereafter existing
for any purposes without the prior written permission of DHCS. Except as
otherwise set forth herein, neither the Contractor nor DHCS shall give any
ownership interest in or rights to its Intellectual Property to the other Party. If
during the term of this Agreement, Contractor accesses any third-party
Intellectual Property that is licensed to DHCS, Contractor agrees to abide by
all license and confidentiality restrictions applicable to DHCS in the third-
party's license agreement.
(4) Contractor agrees to cooperate with DHCS in establishing or maintaining
DHCS' exclusive rights in the Intellectual Property, and in assuring DHCS'
sole rights against third parties with respect to the Intellectual Property. If the
Contractor enters into any agreements or subcontracts with other parties in
order to perform this Agreement, Contractor shall require the terms of the
Agreement(s) to include all Intellectual Property provisions. Such terms must
include, but are not limited to, the subcontractor assigning and agreeing to
assign to DHCS all rights, title and interest in Intellectual Property made,
conceived, derived from, or reduced to practice by the subcontractor,
Contractor or DHCS and which result directly or indirectly from this
Agreement or any subcontract.
(5) Contractor further agrees to assist and cooperate with DHCS in all
reasonable respects, and execute all documents and, subject to reasonable
availability, give testimony and take all further acts reasonably necessary to
acquire, transfer, maintain, and enforce DHCS' Intellectual Property rights
and interests.
Revised 08/2021 Page 16 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
b. Retained Rights / License Rights
(1) Except for Intellectual Property made, conceived, derived from, or reduced to
practice by Contractor or DHCS and which result directly or indirectly from
this Agreement, Contractor shall retain title to all of its Intellectual Property to
the extent such Intellectual Property is in existence prior to the effective date
of this Agreement. Contractor hereby grants to DHCS, without additional
compensation, a permanent, non-exclusive, royalty free, paid-up, worldwide,
irrevocable, perpetual, non-terminable license to use, reproduce,
manufacture, sell, offer to sell, import, export, modify, publicly and privately
display/perform, distribute, and dispose Contractor's Intellectual Property with
the right to sublicense through multiple layers, for any purpose whatsoever, to
the extent it is incorporated in the Intellectual Property resulting from this
Agreement, unless Contractor assigns all rights, title and interest in the
Intellectual Property as set forth herein.
(2) Nothing in this provision shall restrict, limit, or otherwise prevent Contractor
from using any ideas, concepts, know-how, methodology or techniques
related to its performance under this Agreement, provided that Contractor's
use does not infringe the patent, copyright, trademark rights, license or other
Intellectual Property rights of DHCS or third party, or result in a breach or
default of any provisions of this Exhibit or result in a breach of any provisions
of law relating to confidentiality.
c. Copyright
(1) Contractor agrees that for purposes of copyright law, all works [as defined in
Paragraph a, subparagraph (2)(a) of this provision] of authorship made by or
on behalf of Contractor in connection with Contractor's performance of this
Agreement shall be deemed "works made for hire". Contractor further agrees
that the work of each person utilized by Contractor in connection with the
performance of this Agreement will be a "work made for hire," whether that
person is an employee of Contractor or that person has entered into an
agreement with Contractor to perform the work. Contractor shall enter into a
written agreement with any such person that: (i) all work performed for
Contractor shall be deemed a "work made for hire" under the Copyright Act
and (ii) that person shall assign all right, title, and interest to DHCS to any
work product made, conceived, derived from, or reduced to practice by
Contractor or DHCS and which result directly or indirectly from this
Agreement.
(2) All materials, including, but not limited to, visual works or text, reproduced or
distributed pursuant to this Agreement that include Intellectual Property made,
conceived, derived from, or reduced to practice by Contractor or DHCS and
which result directly or indirectly from this Agreement, shall include DHCS'
notice of copyright, which shall read in 3mm or larger typeface: V [Enter
Current Year e.g., 2010, etc.], California Department of Health Care Services.
This material may not be reproduced or disseminated without prior written
permission from the California Department of Health Care Services." This
notice should be placed prominently on the materials and set apart from other
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Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
matter on the page where it appears. Audio productions shall contain a similar
audio notice of copyright.
d. Patent Rights
With respect to inventions made by Contractor in the performance of this
Agreement, which did not result from research and development specifically
included in the Agreement's scope of work, Contractor hereby grants to DHCS a
license as described under Section b of this provision for devices or material
incorporating, or made through the use of such inventions. If such inventions
result from research and development work specifically included within the
Agreement's scope of work, then Contractor agrees to assign to DHCS, without
additional compensation, all its right, title and interest in and to such inventions
and to assist DHCS in securing United States and foreign patents with respect
thereto.
e. Third-Party Intellectual Property
Except as provided herein, Contractor agrees that its performance of this
Agreement shall not be dependent upon or include any Intellectual Property of
Contractor or third party without first: (i) obtaining DHCS' prior written approval;
and (ii) granting to or obtaining for DHCS, without additional compensation, a
license, as described in Section b of this provision, for any of Contractor's or
third-party's Intellectual Property in existence prior to the effective date of this
Agreement. If such a license upon the these terms is unattainable, and DHCS
determines that the Intellectual Property should be included in or is required for
Contractor's performance of this Agreement, Contractor shall obtain a license
under terms acceptable to DHCS.
f. Warranties
(1) Contractor represents and warrants that:
(a) It is free to enter into and fully perform this Agreement.
(b) It has secured and will secure all rights and licenses necessary for its
performance of this Agreement.
(c) Neither Contractor's performance of this Agreement, nor the exercise by
either Party of the rights granted in this Agreement, nor any use,
reproduction, manufacture, sale, offer to sell, import, export, modification,
public and private display/performance, distribution, and disposition of the
Intellectual Property made, conceived, derived from, or reduced to
practice by Contractor or DHCS and which result directly or indirectly from
this Agreement will infringe upon or violate any Intellectual Property right,
non-disclosure obligation, or other proprietary right or interest of any third-
party or entity now existing under the laws of, or hereafter existing or
issued by, any state, the United States, or any foreign country. There is
currently no actual or threatened claim by any such third party based on
an alleged violation of any such right by Contractor.
Revised 08/2021 Page 18 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
(d) Neither Contractor's performance nor any part of its performance will
violate the right of privacy of, or constitute a libel or slander against any
person or entity.
(e) It has secured and will secure all rights and licenses necessary for
Intellectual Property including, but not limited to, consents, waivers or
releases from all authors of music or performances used, and talent
(radio, television and motion picture talent), owners of any interest in and
to real estate, sites, locations, property or props that may be used or
shown.
(f) It has not granted and shall not grant to any person or entity any right that
would or might derogate, encumber, or interfere with any of the rights
granted to DHCS in this Agreement.
(g) It has appropriate systems and controls in place to ensure that state funds
will not be used in the performance of this Agreement for the acquisition,
operation or maintenance of computer software in violation of copyright
laws.
(h) It has no knowledge of any outstanding claims, licenses or other charges,
liens, or encumbrances of any kind or nature whatsoever that could affect
in any way Contractor's performance of this Agreement.
(2) DHCS makes no warranty that the intellectual property resulting from this
agreement does not infringe upon any patent, trademark, copyright or the like,
now existing or subsequently issued.
g. Intellectual Property Indemnity
(1) Contractor shall indemnify, defend and hold harmless DHCS and its licensees
and assignees, and its officers, directors, employees, agents, representatives,
successors, and users of its products, ("Indemnitees") from and against all
claims, actions, damages, losses, liabilities (or actions or proceedings with
respect to any thereof), whether or not rightful, arising from any and all
actions or claims by any third party or expenses related thereto (including, but
not limited to, all legal expenses, court costs, and attorney's fees incurred in
investigating, preparing, serving as a witness in, or defending against, any
such claim, action, or proceeding, commenced or threatened) to which any of
the Indemnitees may be subject, whether or not Contractor is a party to any
pending or threatened litigation, which arise out of or are related to (i) the
incorrectness or breach of any of the representations, warranties, covenants
or agreements of Contractor pertaining to Intellectual Property; or (ii) any
Intellectual Property infringement, or any other type of actual or alleged
infringement claim, arising out of DHCS' use, reproduction, manufacture,
sale, offer to sell, distribution, import, export, modification, public and private
performance/display, license, and disposition of the Intellectual Property
made, conceived, derived from, or reduced to practice by Contractor or DHCS
and which result directly or indirectly from this Agreement. This indemnity
obligation shall apply irrespective of whether the infringement claim is based
Revised 08/2021 Page 19 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
on a patent, trademark or copyright registration that issued after the effective
date of this Agreement. DHCS reserves the right to participate in and/or
control, at Contractor's expense, any such infringement action brought
against DHCS.
(2) Should any Intellectual Property licensed by the Contractor to DHCS under
this Agreement become the subject of an Intellectual Property infringement
claim, Contractor will exercise its authority reasonably and in good faith to
preserve DHCS' right to use the licensed Intellectual Property in accordance
with this Agreement at no expense to DHCS. DHCS shall have the right to
monitor and appear through its own counsel (at Contractor's expense) in any
such claim or action. In the defense or settlement of the claim, Contractor
may obtain the right for DHCS to continue using the licensed Intellectual
Property; or, replace or modify the licensed Intellectual Property so that the
replaced or modified Intellectual Property becomes non-infringing provided
that such replacement or modification is functionally equivalent to the original
licensed Intellectual Property. If such remedies are not reasonably available,
DHCS shall be entitled to a refund of all monies paid under this Agreement,
without restriction or limitation of any other rights and remedies available at
law or in equity.
(3) Contractor agrees that damages alone would be inadequate to compensate
DHCS for breach of any term of this Intellectual Property Exhibit by
Contractor. Contractor acknowledges DHCS would suffer irreparable harm in
the event of such breach and agrees DHCS shall be entitled to obtain
equitable relief, including without limitation an injunction, from a court of
competent jurisdiction, without restriction or limitation of any other rights and
remedies available at law or in equity.
h. Federal Funding
In any agreement funded in whole or in part by the federal government, DHCS
may acquire and maintain the Intellectual Property rights, title, and ownership,
which results directly or indirectly from the Agreement; except as provided in 37
Code of Federal Regulations part 401.14; however, the federal government shall
have a non-exclusive, nontransferable, irrevocable, paid-up license throughout
the world to use, duplicate, or dispose of such Intellectual Property throughout
the world in any manner for governmental purposes and to have and permit
others to do so.
i. Survival
The provisions set forth herein shall survive any termination or expiration of this
Agreement or any project schedule.
Revised 08/2021 Page 20 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
12.Air or Water Pollution Requirements
Any federally funded agreement and/or subcontract in excess of$100,000 must
comply with the following provisions unless said agreement is exempt by law.
a. Government contractors agree to comply with all applicable standards, orders, or
requirements issued under section 306 of the Clean Air Act (42 USC 7606)
section 508 of the Clean Water Act (33 U.S.C. 1368), Executive Order 11738,
and Environmental Protection Agency regulations.
b. Institutions of higher education, hospitals, nonprofit organizations and
commercial businesses agree to comply with all applicable standards, orders, or
requirements issued under the Clean Air Act (42 U.S.C. 7401 et seq.), as
amended, and the Clean Water Act (33 U.S.C. 1251 et seq.), as amended.
13.Prior Approval of Training Seminars, Workshops or Conferences
Contractor shall obtain prior DHCS approval of the location, costs, dates, agenda,
instructors, instructional materials, and attendees at any reimbursable training
seminar, workshop, or conference conducted pursuant to this Agreement and of any
reimbursable publicity or educational materials to be made available for distribution.
The Contractor shall acknowledge the support of the State whenever publicizing the
work under this Agreement in any media. This provision does not apply to necessary
staff meetings or training sessions held for the staff of the Contractor or
Subcontractor to conduct routine business matters.
14.Confidentiality of Information
a. The Contractor and its employees, agents, or subcontractors shall protect from
unauthorized disclosure names and other identifying information concerning
persons either receiving services pursuant to this Agreement or persons whose
names or identifying information become available or are disclosed to the
Contractor, its employees, agents, or subcontractors as a result of services
performed under this Agreement, except for statistical information not identifying
any such person.
b. The Contractor and its employees, agents, or subcontractors shall not use such
identifying information for any purpose other than carrying out the Contractor's
obligations under this Agreement.
c. The Contractor and its employees, agents, or subcontractors shall promptly
transmit to the DHCS Program Contract Manager all requests for disclosure of
such identifying information not emanating from the client or person.
d. The Contractor shall not disclose, except as otherwise specifically permitted by
this Agreement or authorized by the client, any such identifying information to
anyone other than DHCS without prior written authorization from the DHCS
Program Contract Manager, except if disclosure is required by State or Federal
law.
Revised 08/2021 Page 21 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
e. For purposes of this provision, identity shall include, but not be limited to name,
identifying number, symbol, or other identifying particular assigned to the
individual, such as finger or voice print or a photograph.
f. As deemed applicable by DHCS, this provision may be supplemented by
additional terms and conditions covering personal health information (PHI) or
personal, sensitive, and/or confidential information (PSCI). Said terms and
conditions will be outlined in one or more exhibits that will either be attached to
this Agreement or incorporated into this Agreement by reference.
15.Documents, Publications and Written Reports
(Applicable to agreements over $5,000 under which publications, written reports and
documents are developed or produced. Government Code Section 7550.)
Any document, publication or written report (excluding progress reports, financial
reports and normal contractual communications) prepared as a requirement of this
Agreement shall contain, in a separate section preceding the main body of the
document, the number and dollar amounts of all contracts or agreements and
subcontracts relating to the preparation of such document or report, if the total cost
for work by nonemployees of the State exceeds $5,000.
16.Dispute Resolution Process
a. A Contractor grievance exists whenever there is a dispute arising from DHCS'
action in the administration of an agreement. If there is a dispute or grievance
between the Contractor and DHCS, the Contractor must seek resolution using
the procedure outlined below.
(1) The Contractor should first informally discuss the problem with the DHCS
Program Contract Manager. If the problem cannot be resolved informally, the
Contractor shall direct its grievance together with any evidence, in writing, to
the program Branch Chief. The grievance shall state the issues in dispute, the
legal authority or other basis for the Contractor's position and the remedy
sought. The Branch Chief shall render a decision within ten (10) working days
after receipt of the written grievance from the Contractor. The Branch Chief
shall respond in writing to the Contractor indicating the decision and reasons
therefore. If the Contractor disagrees with the Branch Chief's decision, the
Contractor may appeal to the second level.
(2) When appealing to the second level, the Contractor must prepare an appeal
indicating the reasons for disagreement with Branch Chief's decision. The
Contractor shall include with the appeal a copy of the Contractor's original
statement of dispute along with any supporting evidence and a copy of the
Branch Chief's decision. The appeal shall be addressed to the Deputy
Director of the division in which the branch is organized within ten (10)
working days from receipt of the Branch Chief's decision. The Deputy Director
of the division in which the branch is organized or his/her designee shall meet
with the Contractor to review the issues raised. A written decision signed by
the Deputy Director of the division in which the branch is organized or his/her
Revised 08/2021 Page 22 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
designee shall be directed to the Contractor within twenty (20) working days
of receipt of the Contractor's second level appeal.
b. If the Contractor wishes to appeal the decision of the Deputy Director of the
division in which the branch is organized or his/her designee, the Contractor shall
follow the procedures set forth in Health and Safety Code Section 100171.
c. Unless otherwise stipulated in writing by DHCS, all dispute, grievance and/or
appeal correspondence shall be directed to the DHCS Program Contract
Manager.
d. There are organizational differences within DHCS' funding programs and the
management levels identified in this dispute resolution provision may not apply in
every contractual situation. When a grievance is received and organizational
differences exist, the Contractor shall be notified in writing by the DHCS Program
Contract Manager of the level, name, and/or title of the appropriate management
official that is responsible for issuing a decision at a given level.
17.Financial and Compliance Audit Requirements
a. The definitions used in this provision are contained in Section 38040 of the
Health and Safety Code, which by this reference is made a part hereof.
b. Direct service contract means a contract or agreement for services contained in
local assistance or subvention programs or both (see Health and Safety [H&S]
Code Section 38020). Direct service contracts shall not include contracts,
agreements, grants, or subventions to other governmental agencies or units of
government nor contracts or agreements with regional centers or area agencies
on aging (H&S Code Section 38030).
c. The Contractor, as indicated below, agrees to obtain one of the following audits:
(1) If the Contractor is a nonprofit organization (as defined in H&S Code
Section 38040) and receives $25,000 or more from any State agency under
a direct service contract or agreement; the Contractor agrees to obtain an
annual single, organization wide, financial and compliance audit. Said audit
shall be conducted according to Generally Accepted Auditing Standards. This
audit does not fulfill the audit requirements of Paragraph c(3) below. The audit
shall be completed by the 15th day of the fifth month following the end of the
Contractor's fiscal year, and/or
(2) If the Contractor is a nonprofit organization (as defined in H&S Code
Section 38040) and receives less than $25,000 per year from any State
agency under a direct service contract or agreement, the Contractor agrees to
obtain a biennial single, organization wide financial and compliance audit,
unless there is evidence of fraud or other violation of state law in connection
with this Agreement. This audit does not fulfill the audit requirements of
Paragraph c(3) below. The audit shall be completed by the 15th day of the
fifth month following the end of the Contractor's fiscal year, and/or
Revised 08/2021 Page 23 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
(3) If the Contractor is a State or Local Government entity or Nonprofit
organization (as defined by 2 C.F.R. §§ 200.64, 200.70, and 200.90) and
expends $750,000 or more in Federal awards, the Contractor agrees to
obtain an annual single, organization wide, financial and compliance audit
according to the requirements specified in 2 C.F.R. 200.501 entitled "Audit
Requirements". An audit conducted pursuant to this provision will fulfill the
audit requirements outlined in Paragraphs c(1) and c(2) above. The audit
shall be completed by the end of the ninth month following the end of the
audit period. The requirements of this provision apply if:
(a) The Contractor is a recipient expending Federal awards received directly
from Federal awarding agencies, or
(b) The Contractor is a subrecipient expending Federal awards received from
a pass-through entity such as the State, County or community based
organization.
(4) If the Contractor submits to DHCS a report of an audit other than a 2 C.F.R.
200.501 audit, the Contractor must also submit a certification indicating the
Contractor has not expended $750,000 or more in federal funds for the year
covered by the audit report.
d. Two copies of the audit report shall be delivered to the DHCS program funding
this Agreement. The audit report must identify the Contractor's legal name and
the number assigned to this Agreement. The audit report shall be due within 30
days after the completion of the audit. Upon receipt of said audit report, the
DHCS Program Contract Manager shall forward the audit report to DHCS' Audits
and Investigations Unit if the audit report was submitted under Section 16.c(3),
unless the audit report is from a City, County, or Special District within the State
of California whereby the report will be retained by the funding program.
e. The cost of the audits described herein may be included in the funding for this
Agreement up to the proportionate amount this Agreement represents of the
Contractor's total revenue. The DHCS program funding this Agreement must
provide advance written approval of the specific amount allowed for said audit
expenses.
f. The State or its authorized designee, including the Bureau of State Audits, is
responsible for conducting agreement performance audits which are not financial
and compliance audits. Performance audits are defined by Generally Accepted
Government Auditing Standards.
g. Nothing in this Agreement limits the State's responsibility or authority to enforce
State law or regulations, procedures, or reporting requirements arising thereto.
h. Nothing in this provision limits the authority of the State to make audits of this
Agreement, provided however, that if independent audits arranged for by the
Contractor meet Generally Accepted Governmental Auditing Standards, the
State shall rely on those audits and any additional audit work and shall build
upon the work already done.
Revised 08/2021 Page 24 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
i. The State may, at its option, direct its own auditors to perform either of the audits
described above. The Contractor will be given advance written notification, if the
State chooses to exercise its option to perform said audits.
j. The Contractor shall include a clause in any agreement the Contractor enters
into with the audit firm doing the single organization wide audit to provide access
by the State or Federal Government to the working papers of the independent
auditor who prepares the single organization wide audit for the Contractor.
k. Federal or state auditors shall have "expanded scope auditing" authority to
conduct specific program audits during the same period in which a single
organization wide audit is being performed, but the audit report has not been
issued. The federal or state auditors shall review and have access to the current
audit work being conducted and will not apply any testing or review procedures
which have not been satisfied by previous audit work that has been completed.
The term "expanded scope auditing" is applied and defined in the U.S. General
Accounting Office (GAO) issued Standards for Audit of Government
Organizations, Programs, Activities and Functions, better known as the "yellow
book".
18.Human Subjects Use Requirements
(Applicable only to federally funded agreements/grants in which performance,
directly or through a subcontract/subaward, includes any tests or examination of
materials derived from the human body.)
By signing this Agreement, Contractor agrees that if any performance under this
Agreement or any subcontract or subagreement includes any tests or examination of
materials derived from the human body for the purpose of providing information,
diagnosis, prevention, treatment or assessment of disease, impairment, or health of
a human being, all locations at which such examinations are performed shall meet
the requirements of 42 U.S.C. Section 263a (CLIA) and the regulations thereunder.
19.Novation Requirements
If the Contractor proposes any novation agreement, DHCS shall act upon the
proposal within 60 days after receipt of the written proposal. DHCS may review and
consider the proposal, consult and negotiate with the Contractor, and accept or
reject all or part of the proposal. Acceptance or rejection of the proposal may be
made orally within the 60-day period and confirmed in writing within five days of said
decision. Upon written acceptance of the proposal, DHCS will initiate an amendment
to this Agreement to formally implement the approved proposal.
20.Debarment and Suspension Certification
(Applicable to all agreements funded in part or whole with federal funds.)
a. By signing this Agreement, the Contractor/Grantee agrees to comply with
applicable federal suspension and debarment regulations including, but not
limited to 2 CFR 180, 2 CFR 376
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Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
b. By signing this Agreement, the Contractor certifies to the best of its knowledge
and belief, that it and its principals:
(1) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any federal department or agency;
(2) Have not within a three-year period preceding this
application/proposal/agreement been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) violation of Federal or State antitrust statutes; or
commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, tax evasion, receiving stolen
property, making false claims, obstruction of justice, or the commission of any
other offense indicating a lack of business integrity or business honesty that
seriously affects its business honesty;
(3) Are not presently indicted for or otherwise criminally or civilly charged by a
governmental entity (Federal, State or local) with commission of any of the
offenses enumerated in Paragraph b(2) herein; and
(4) Have not within a three-year period preceding this
application/proposal/agreement had one or more public transactions (Federal,
State or local) terminated for cause or default.
(5) Have not, within a three-year period preceding this
application/proposal/agreement, engaged in any of the violations listed under
2 CFR Part 180, Subpart C as supplemented by 2 CFR Part 376.
(6) Shall not knowingly enter into any lower tier covered transaction with a person
who is proposed for debarment under federal regulations (i.e., 48 CFR part 9,
subpart 9.4), debarred, suspended, declared ineligible, or voluntarily excluded
from participation in such transaction, unless authorized by the State.
(7) Will include a clause entitled, "Debarment and Suspension Certification" that
essentially sets forth the provisions herein, in all lower tier covered
transactions and in all solicitations for lower tier covered transactions.
c. If the Contractor is unable to certify to any of the statements in this certification,
the Contractor shall submit an explanation to the DHCS Program Contract
Manager.
d. The terms and definitions herein have the meanings set out in 2 CFR Part 180 as
supplemented by 2 CFR Part 376.
e. If the Contractor knowingly violates this certification, in addition to other remedies
available to the Federal Government, the DHCS may terminate this Agreement
for cause or default.
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Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
21.Smoke-Free Workplace Certification
(Applicable to federally funded agreements/grants and subcontracts/subawards, that
provide health, day care, early childhood development services, education or library
services to children under 18 directly or through local governments.)
a. Public Law 103-227, also known as the Pro-Children Act of 1994 (Act), requires
that smoking not be permitted in any portion of any indoor facility owned or
leased or contracted for by an entity and used routinely or regularly for the
provision of health, day care, early childhood development services, education or
library services to children under the age of 18, if the services are funded by
federal programs either directly or through state or local governments, by federal
grant, contract, loan, or loan guarantee. The law also applies to children's
services that are provided in indoor facilities that are constructed, operated, or
maintained with such federal funds. The law does not apply to children's services
provided in private residences; portions of facilities used for inpatient drug or
alcohol treatment; service providers whose sole source of applicable federal
funds is Medicare or Medicaid; or facilities where WIC coupons are redeemed.
b. Failure to comply with the provisions of the law may result in the imposition of a
civil monetary penalty of up to $1,000 for each violation and/or the imposition of
an administrative compliance order on the responsible party.
c. By signing this Agreement, Contractor or Grantee certifies that it will comply with
the requirements of the Act and will not allow smoking within any portion of any
indoor facility used for the provision of services for children as defined by the Act.
The prohibitions herein are effective December 26, 1994.
d. Contractor or Grantee further agrees that it will insert this certification into any
subawards (subcontracts or subgrants) entered into that provide for children's
services as described in the Act.
22.Covenant Against Contingent Fees
(Applicable only to federally funded agreements.)
The Contractor warrants that no person or selling agency has been employed or
retained to solicit/secure this Agreement upon an agreement of understanding for a
commission, percentage, brokerage, or contingent fee, except bona fide employees
or bona fide established commercial or selling agencies retained by the Contractor
for the purpose of securing business. For breach or violation of this warranty, DHCS
shall have the right to annul this Agreement without liability or in its discretion to
deduct from the Agreement price or consideration, or otherwise recover, the full
amount of such commission, percentage, and brokerage or contingent fee.
Revised 08/2021 Page 27 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
23.Payment Withholds
(Applicable only if a final report is required by this Agreement. Not applicable to
government entities.)
Unless waived or otherwise stipulated in this Agreement, DHCS may, at its
discretion, withhold 10 percent (10%) of the face amount of the Agreement, 50
percent (50%) of the final invoice, or $3,000 whichever is greater, until DHCS
receives a final report that meets the terms, conditions and/or scope of work
requirements of this Agreement.
24.Performance Evaluation
(Not applicable to grant agreements.)
DHCS may, at its discretion, evaluate the performance of the Contractor at the
conclusion of this Agreement. If performance is evaluated, the evaluation shall not
be a public record and shall remain on file with DHCS. Negative performance
evaluations may be considered by DHCS prior to making future contract awards.
25.Officials Not to Benefit
No members of or delegate of Congress or the State Legislature shall be admitted to
any share or part of this Agreement, or to any benefit that may arise therefrom. This
provision shall not be construed to extend to this Agreement if made with a
corporation for its general benefits.
26.Four-Digit Date Compliance
(Applicable to agreements in which Information Technology (IT) services are
provided to DHCS or if IT equipment is procured.)
Contractor warrants that it will provide only Four-Digit Date Compliant (as defined
below) Deliverables and/or services to the State. "Four Digit Date compliant"
Deliverables and services can accurately process, calculate, compare, and
sequence date data, including without limitation date data arising out of or relating to
leap years and changes in centuries. This warranty and representation is subject to
the warranty terms and conditions of this Contract and does not limit the generality
of warranty obligations set forth elsewhere herein.
27.Prohibited Use of State Funds for Software
(Applicable to agreements in which computer software is used in performance of the
work.)
Contractor certifies that it has appropriate systems and controls in place to ensure
that state funds will not be used in the performance of this Agreement for the
acquisition, operation or maintenance of computer software in violation of copyright
laws.
Revised 08/2021 Page 28 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
28.Use of Small, Minority Owned and Women's Businesses
(Applicable to that portion of an agreement that is federally funded and entered into
with institutions of higher education, hospitals, nonprofit organizations or commercial
businesses.)
Positive efforts shall be made to use small businesses, minority-owned firms and
women's business enterprises, whenever possible (i.e., procurement of goods
and/or services). Contractors shall take all of the following steps to further this goal.
a. Ensure that small businesses, minority-owned firms, and women's business
enterprises are used to the fullest extent practicable.
b. Make information on forthcoming purchasing and contracting opportunities
available and arrange time frames for purchases and contracts to encourage and
facilitate participation by small businesses, minority-owned firms, and women's
business enterprises.
c. Consider in the contract process whether firms competing for larger contracts
intend to subcontract with small businesses, minority-owned firms, and women's
business enterprises.
d. Encourage contracting with consortiums of small businesses, minority-owned
firms and women's business enterprises when a contract is too large for one of
these firms to handle individually.
e. Use the services and assistance, as appropriate, of such organizations as the
Federal Small Business Administration and the U.S. Department of Commerce's
Minority Business Development Agency in the solicitation and utilization of small
businesses, minority-owned firms and women's business enterprises.
29.Alien Ineligibility Certification
(Applicable to sole proprietors entering federally funded agreements.)
By signing this Agreement, the Contractor certifies that he/she is not an alien that is
ineligible for state and local benefits, as defined in Subtitle B of the Personal
Responsibility and Work Opportunity Act. (8 U.S.C. 1601, et seq.)
30.Union Organizing
(Applicable only to grant agreements.)
Grantee, by signing this Agreement, hereby acknowledges the applicability of
Government Code Sections 16645 through 16649 to this Agreement. Furthermore,
Grantee, by signing this Agreement, hereby certifies that:
a. No state funds disbursed by this grant will be used to assist, promote or deter
union organizing.
b. Grantee shall account for state funds disbursed for a specific expenditure by this
grant, to show those funds were allocated to that expenditure.
Revised 08/2021 Page 29 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
c. Grantee shall, where state funds are not designated as described in b herein,
allocate, on a pro-rata basis, all disbursements that support the grant program.
d. If Grantee makes expenditures to assist, promote or deter union organizing,
Grantee will maintain records sufficient to show that no state funds were used for
those expenditures, and that Grantee shall provide those records to the Attorney
General upon request.
31.Contract Uniformity (Fringe Benefit Allowability)
(Applicable only to nonprofit organizations.)
Pursuant to the provisions of Article 7 (commencing with Section 100525) of Chapter
3 of Part 1 of Division 101 of the Health and Safety Code, DHCS sets forth the
following policies, procedures, and guidelines regarding the reimbursement of fringe
benefits.
a. As used herein fringe benefits shall mean an employment benefit given by one's
employer to an employee in addition to one's regular or normal wages or salary.
b. As used herein, fringe benefits do not include:
(1) Compensation for personal services paid currently or accrued by the
Contractor for services of employees rendered during the term of this
Agreement, which is identified as regular or normal salaries and wages,
annual leave, vacation, sick leave, holidays, jury duty and/or military
leave/training.
(2) Director's and executive committee member's fees.
(3) Incentive awards and/or bonus incentive pay.
(4) Allowances for off-site pay.
(5) Location allowances.
(6) Hardship pay.
(7) Cost-of-living differentials
c. Specific allowable fringe benefits include:
(1) Fringe benefits in the form of employer contributions for the employer's
portion of payroll taxes (i.e., FICA, SUI, SDI), employee health plans (i.e.,
health, dental and vision), unemployment insurance, worker's compensation
insurance, and the employer's share of pension/retirement plans, provided
they are granted in accordance with established written organization policies
and meet all legal and Internal Revenue Service requirements.
Revised 08/2021 Page 30 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
d. To be an allowable fringe benefit, the cost must meet the following criteria:
(1) Be necessary and reasonable for the performance of the Agreement.
(2) Be determined in accordance with generally accepted accounting principles.
(3) Be consistent with policies that apply uniformly to all activities of the
Contractor.
e. Contractor agrees that all fringe benefits shall be at actual cost.
f. Earned/Accrued Compensation
(1) Compensation for vacation, sick leave and holidays is limited to that amount
earned/accrued within the agreement term. Unused vacation, sick leave and
holidays earned from periods prior to the agreement term cannot be claimed
as allowable costs. See Provision f (3)(a) for an example.
(2) For multiple year agreements, vacation and sick leave compensation, which
is earned/accrued but not paid, due to employee(s) not taking time off may be
carried over and claimed within the overall term of the multiple years of the
Agreement. Holidays cannot be carried over from one agreement year to the
next. See Provision f (3)(b) for an example.
(3) For single year agreements, vacation, sick leave and holiday compensation
that is earned/accrued but not paid, due to employee(s) not taking time off
within the term of the Agreement, cannot be claimed as an allowable cost.
See Provision f (3)(c) for an example.
(a) Example No. 1:
If an employee, John Doe, earns/accrues three weeks of vacation and
twelve days of sick leave each year, then that is the maximum amount that
may be claimed during a one year agreement. If John Doe has five weeks
of vacation and eighteen days of sick leave at the beginning of an
agreement, the Contractor during a one-year budget period may only
claim up to three weeks of vacation and twelve days of sick leave as
actually used by the employee. Amounts earned/accrued in periods prior
to the beginning of the Agreement are not an allowable cost.
(b) Example No. 2:
If during a three-year (multiple year) agreement, John Doe does not use
his three weeks of vacation in year one, or his three weeks in year two,
but he does actually use nine weeks in year three; the Contractor would
be allowed to claim all nine weeks paid for in year three. The total
compensation over the three-year period cannot exceed 156 weeks (3 x
52 weeks).
Revised 08/2021 Page 31 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
(c) Example No. 3:
If during a single year agreement, John Doe works fifty weeks and used
one week of vacation and one week of sick leave and all fifty-two weeks
have been billed to DHCS, the remaining unused two weeks of vacation
and seven days of sick leave may not be claimed as an allowable cost.
32.Suspension or Stop Work Notification
a. DHCS may, at any time, issue a notice to suspend performance or stop work
under this Agreement. The initial notification may be a verbal or written directive
issued by the funding Program's Contract Manager. Upon receipt of said notice,
the Contractor is to suspend and/or stop all, or any part, of the work called for by
this Agreement.
b. Written confirmation of the suspension or stop work notification with directions as
to what work (if not all) is to be suspended and how to proceed will be provided
within 30 working days of the verbal notification. The suspension or stop work
notification shall remain in effect until further written notice is received from
DHCS. The resumption of work (in whole or part) will be at DHCS' discretion and
upon receipt of written confirmation.
(1) Upon receipt of a suspension or stop work notification, the Contractor shall
immediately comply with its terms and take all reasonable steps to minimize
or halt the incurrence of costs allocable to the performance covered by the
notification during the period of work suspension or stoppage.
(2) Within 90 days of the issuance of a suspension or stop work notification,
DHCS shall either:
(a) Cancel, extend, or modify the suspension or stop work notification; or
(b) Terminate the Agreement as provided for in the Cancellation / Termination
clause of the Agreement.
c. If a suspension or stop work notification issued under this clause is canceled or
the period of suspension or any extension thereof is modified or expires, the
Contractor may resume work only upon written concurrence of funding Program's
Contract Manager.
d. If the suspension or stop work notification is cancelled and the Agreement
resumes, changes to the services, deliverables, performance dates, and/or
contract terms resulting from the suspension or stop work notification shall
require an amendment to the Agreement.
e. If a suspension or stop work notification is not canceled and the Agreement is
cancelled or terminated pursuant to the provision entitled Cancellation /
Termination, DHCS shall allow reasonable costs resulting from the suspension or
stop work notification in arriving at the settlement costs.
Revised 08/2021 Page 32 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
f. DHCS shall not be liable to the Contractor for loss of profits because of any
suspension or stop work notification issued under this clause.
33.Public Communications
"Electronic and printed documents developed and produced, for public
communications shall follow the following requirements to comply with Section 508
of the Rehabilitation Act and the American with Disabilities Act:
a. Ensure visual-impaired, hearing-impaired and other special needs audiences are
provided material information in formats that provide the most assistance in
making informed choices."
34.Compliance with Statutes and Regulations
a. The Contractor shall comply with all California and federal law, regulations, and
published guidelines, to the extent that these authorities contain requirements
applicable to Contractor's performance under the Agreement.
b. These authorities include, but are not limited to, Title 2, Code of Federal
Regulations (CFR) Part 200, subpart F, Appendix II; Title 42 CFR Part 431,
subpart F; Title 42 CFR Part 433, subpart D; Title 42 CFR Part 434; Title 45 CFR
Part 75, subpart D; and Title 45 CFR Part 95, subpart F. To the extent applicable
under federal law, this Agreement shall incorporate the contractual provisions in
these federal regulations and they shall supersede any conflicting provisions in
this Agreement.
35.Lobbying Restrictions and Disclosure Certification
(Applicable to federally funded agreements in excess of $100,000 per Section 1352
of the 31, U.S.C.)
a. Certification and Disclosure Requirements
(1) Each person (or recipient) who requests or receives a contract or agreement,
subcontract, grant, or subgrant, which is subject to Section 1352 of the 31,
U.S.C., and which exceeds $100,000 at any tier, shall file a certification (in
the form set forth in Attachment 1, consisting of one page, entitled
"Certification Regarding Lobbying") that the recipient has not made, and will
not make, any payment prohibited by Paragraph b of this provision.
(2) Each recipient shall file a disclosure (in the form set forth in Attachment 2,
entitled "Standard Form-LLL 'disclosure of Lobbying Activities"') if such
recipient has made or has agreed to make any payment using
nonappropriated funds (to include profits from any covered federal action) in
connection with a contract, or grant or any extension or amendment of that
contract, or grant, which would be prohibited under Paragraph b of this
provision if paid for with appropriated funds.
Revised 08/2021 Page 33 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
(3) Each recipient shall file a disclosure form at the end of each calendar quarter
in which there occurs any event that requires disclosure or that materially
affect the accuracy of the information contained in any disclosure form
previously filed by such person under Paragraph a(2) herein. An event that
materially affects the accuracy of the information reported includes:
(a) A cumulative increase of $25,000 or more in the amount paid or expected
to be paid for influencing or attempting to influence a covered federal
action;
(b) A change in the person(s) or individuals(s) influencing or attempting to
influence a covered federal action; or
(c) A change in the officer(s), employee(s), or member(s) contacted for the
purpose of influencing or attempting to influence a covered federal action.
(4) Each person (or recipient) who requests or receives from a person referred to
in Paragraph a(1) of this provision a contract or agreement, subcontract, grant
or subgrant exceeding $100,000 at any tier under a contract or agreement, or
grant shall file a certification, and a disclosure form, if required, to the next tier
above.
(5) All disclosure forms (but not certifications) shall be forwarded from tier to tier
until received by the person referred to in Paragraph a(1) of this provision.
That person shall forward all disclosure forms to DHCS Program Contract
Manager.
b. Prohibition
Section 1352 of Title 31, U.S.C., provides in part that no appropriated funds may
be expended by the recipient of a federal contract or agreement, grant, loan, or
cooperative agreement to pay any person for influencing or attempting to
influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in
connection with any of the following covered federal actions: the awarding of any
federal contract or agreement, the making of any federal grant, the making of any
federal loan, entering into of any cooperative agreement, and the extension,
continuation, renewal, amendment, or modification of any federal contract or
agreement, grant, loan, or cooperative agreement.
Revised 08/2021 Page 34 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
Attachment 1
CERTIFICATION REGARDING LOBBYING
The undersigned certifies, to the best of his or her knowledge and belief, that:
1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or
employee of an agency, a Member of Congress, an officer or employee of Congress,
or an employee of a Member of Congress in connection with the making, awarding or
entering into of this Federal contract, Federal grant, or cooperative agreement, and
the extension, continuation, renewal, amendment, or modification of this Federal
contract, grant, or cooperative agreement.
2. If any funds other than Federal appropriated funds have been paid or will be paid to
any person for influencing or attempting to influence an officer or employee of any
agency of the United States Government, a Member of Congress, an officer or
employee of Congress, or an employee of a Member of Congress in connection with
this Federal contract, grant, or cooperative agreement, the undersigned shall
complete and submit Standard Form LLL, "Disclosure of Lobbying Activities" in
accordance with its instructions.
3. The undersigned shall require that the language of this certification be included in the
award documents for all subawards at all tiers (including subcontractors, subgrants,
and contracts under grants and cooperative agreements) of $100,000 or more, and
that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when
this transaction was made or entered into. Submission of this certification is a prerequisite
for making or entering into this transaction imposed by Section 1352, Title 31, U.S.C., any
person who fails to file the required certification shall be subject to a civil penalty of not
less than $10,000 and not more than $100,000 for each such failure.
Name of Contractor Printed Name of Person Signing for Contractor
Contract / Grant Number Signature of Person Signing for Contractor
Date Title
Revised 08/2021 Page 35 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
After execution by or on behalf of Contractor, please return to:
California Department of Health Care Services
DHCS reserves the right to notifiy the contractor in writing of an alternate submission
address.
Revised 08/2021 Page 36 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
Attachment 2
CERTIFICATION REGARDING LOBBYING
Approved by OMB (0348-0046)
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
See reverse for public burden disclosure
1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
_ a. contract _ a. bid/offer/application _ a. initial filing
b. grant b. initial award b. material change
c. cooperative agreement c. post-award
For Material Change Only:
d. loan
e. loan guarantee Year quarter
f. loan insurance date of last report
4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee,
Enter Name and Address of Prime:
O Prime O Subawardee
Tier , if known:
Congressional District, If known: Congressional District, If known:
6. Federal Department/Agency 7. Federal Program Name/Description:
CDFA Number, if applicable:
8. Federal Action Number, if known: 9. Award Amount, if known:
10.a. Name and Address of Lobbying Registrant b. Individuals Performing Services
(If individual, last name, first name, MI): (including address if different from 10a.
Last name, First name, MI):
11.Information requested through this form is authorized by title 31 U.S.C. section 1352. This
disclosure of lobbying activities is a material representation of fact upon which reliance was
placed by the tier above when this transaction was made or entered into. This disclosure is
required pursuant to 31 U.S.C. 1352. This information will be available for public inspection. Any
person that fails to file the required disclosure shall be subject to a not more than $100,000 for
each such failure.
Signature:
Print Name: Brian Pacheco
Title: Chairman of the Board of Supervisors of the County of Fresno
Telephone Number:
Date: p-/2 2 2
p Authorized for Local Reproduction
ATTEST:
Standard Form-LLL
BERNICE E.SEIDEL
Clerk of the Board of Supervisors
County of Fresno,Stag of California
Revised 08/2021 Page 37 of 39 By _Deputy
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING
ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee or
prime Federal recipient, at the initiation or receipt of a covered Federal action, or a
material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of
a form is required for each payment or agreement to make payment to any lobbying entity
for influencing or attempting to influence an officer or employee of any agency, a Member
of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with a covered Federal action. Complete all items that apply for
both the initial filing and material change report. Refer to the implementing guidance
published by the Office of Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is and/or has
been secured to influence the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriateclassification of this report. If this is a followup report caused
by a material change to the information previously reported, enter the year and quarter
in which the change occurred. Enter the date of the last previously submitted report
by this reporting entity for this covered Federal action.
4. Enter the full name, address, city, State and zip code of the reporting entity. Include
Congressional District, if known. Check the appropriate classification of the reporting
entity that designates if itis, or expects to be,a prime or subaward recipient. Identify
the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier.
Subawards include but are not limited to subcontracts, subgrants and contract awards
under grants.
5. If the organization filing the report in item 4 checks "Subawardee," then enter the full
name, address, city, State and zip code of the prime Federal recipient. Include
Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include
at least one organizational level below agency name, if known. For example,
Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item
1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number
for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action
identified in item 1 (e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB)
number; grant announcement number; the contract, grant, or loan award number; the
application/proposal control number assigned by the Federal agency). Include
prefixes, e.g., "RFP-DE-90-001".
9. For a covered Federal action where there has been an award or loan commitment by
the Federal agency, enter the Federal amount of the award/loan commitment for the
prime entity identified in item 4 or 5.
Revised 08/2021 Page 38 of 39
Department of Health Care Services 22-20101
County of Fresno Exhibit D(F)
10.(a) Enter the full name, address, city, State and zip code of the lobbying registrant
under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified
in item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full
address if different from 10 (a). Enter Last Name, First Name, and Middle Initial (MI).
11.The certifying official shall sign and date the form, print his/her name, title, and
telephone number.
According to the Paperwork Reduction Act, as amended, no persons are required to
respond to a collection of information unless it displays a valid OMB Control Number.
The valid OMB control number for this information collection is OMB No. 0348-0046.
Public reporting burden for this collection of information is estimated to average 10
minutes per response, including time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to
the Office of Management and Budget, Paperwork Reduction Project (0348-0046),
Washington, DC 20503.
Revised 08/2021 Page 39 of 39
County of Fresno
22-20101
Page 1 of 17
Exhibit E
ADDITIONAL PROVISIONS
1. 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
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.
2. 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
County of Fresno
22-20101
Page 2 of 17
Exhibit E
ADDITIONAL PROVISIONS
Contractor in accordance with Government (Govt.) Code 30027.10.
(Welf. & Inst. Code § 147122(d).)
A. Contract Renewal
1) This contract may be renewed if the Contractor continues to meet
the requirements of Chapter 8.9 of Part 3 of Division 9 of the Welf.
& Inst. Code and implementing regulatory requirements, 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)(2).)
B. 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
County of Fresno
22-20101
Page 3 of 17
Exhibit E
ADDITIONAL PROVISIONS
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
change mutually agreed to by the parties on the condition that the
amendment is approved by the Department of General Services, if
necessary.
C. Contract Termination
The Contractor may terminate this contract in accordance with, Cal. Code
Regs., tit. 9, section 1810.323(a). The Department may terminate this
contract in accordance with Welf. & Inst. Code, sections 14197.7, 14714
and Cal. Code Regs., tit. 9, section 1810.323.
1) DHCS shall terminate this contract if the United States Secretary of
Health and Human Services has determined the Contractor does
not meet the requirements for participation in the Medicaid program
contained in Subchapter XIX (commencing with Section 1396) of
Chapter 7 of Title 42 of the United States Code. (Welf. & Inst. Code
§ 14197.7(i))
2) DHCS reserves the right to cancel or terminate this Contract if
DHCS finds that Contractor fails to comply with contract
requirements, state or federal law or regulations, or the state plan
or approved waivers, or for other good cause. (Welf. & Inst. Code §
14197.7(a))
3) Good cause includes, but is not limited to, a finding of deficiency
that results in improper denial or delay in the delivery of health care
services, potential endangerment to patient care, disruption in the
contractor's provider network, failure to approve continuity of care,
that claims accrued or to accrue have not or will not be
recompensed, or a delay in required contractor report to the
department. (Welf. & Inst. Code § 14197.7(a))
4) Contract termination or cancellation shall be effective as of the date
indicated in DHCS' notification to the Contractor, unless Contractor
appeals the termination, or termination is immediate pursuant to
paragraph 8. The notice shall identify any final performance,
invoicing or payment requirements.
County of Fresno
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Exhibit E
ADDITIONAL PROVISIONS
5) Contractor may appeal contract termination pursuant to Welf. &
Inst. Conde sections 14197.7(1)(2) or section 14714(d).
6) 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.
7) 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.
8) 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).)
D. Termination of Obligations
1) All obligations to provide covered services under this contract shall
automatically terminate on the effective date of any termination of
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 the Contractor terminates a subcontract with a provider, the
Contractor shall make a good faith effort to provide notice of this
termination, within 15 days, to the persons that the Contractor,
based on available information, determines have recently been
receiving services from that provider.
E. Contract Disputes
Should a dispute arise between the Contractor and the Department
relating to performance under this contract, other than disputes governed
County of Fresno
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Exhibit E
ADDITIONAL PROVISIONS
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.
3. 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.
4. 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.
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. The 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,
County of Fresno
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Exhibit E
ADDITIONAL PROVISIONS
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 the 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 the 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.
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:
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Exhibit E
ADDITIONAL PROVISIONS
Department of Health Care Services County of Fresno
Medi-Cal Behavioral Health Division 1925 E. Dakota Ave.
1501 Capitol Avenue, MS 2702 Fresno, CA 93726
Sacramento, CA 95814
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 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), prohibiting exclusion, denial of benefits, and discrimination
against qualified individuals with a disability in any federally
assisted programs or activities, and shall comply with the
implementing regulations in Parts 84 and 85 of Title 45 of the
C.F.R., as applicable.
3) The Contractor shall include the nondiscrimination and compliance
provisions of this contract in all subcontracts to perform work under
this contract.
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
County of Fresno
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Exhibit E
ADDITIONAL PROVISIONS
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.
5. 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
the 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. Code Regs., tit. 9, section
1810.380, subdivision (a), and Welf. & Inst. Code § 14197.7. The
Department shall also arrange for an annual external quality review of the
County of Fresno
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Exhibit E
ADDITIONAL PROVISIONS
Contractor as required by 42 Code of Federal Regulations, part 438.350
and Cal. Code Regs., tit. 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. Failure to comply with required
corrective action could lead to civil penalties, as appropriate, pursuant to
Welf. & Inst. Code § 14197.7.
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.
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.
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Exhibit E
ADDITIONAL PROVISIONS
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. Code Regs., tit. 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 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.
County of Fresno
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Exhibit E
ADDITIONAL PROVISIONS
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.
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 in accordance with Cal. Code Regs., tit. 9, §§
1810.380(a) and impose sanctions on the Contractor for violations of the terms of this
contract, and applicable federal and state law and regulations, or the state plan or
approved waivers, or for other good cause in accordance with Welf. & Inst. Code §
14197.7 and guidance issued by the Department pursuant to subdivision (r) of Welf. &
Inst. Code § 14197.7.
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.
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Exhibit E
ADDITIONAL PROVISIONS
6. State and Federal Law Governing this Contract
A. The Contractor/Subrecipient Designation: the Contractor is considered a
contractor subject to 2 C.F.R Part 200 (45 C.F.R. Part 75).
B. The Contractor agrees to comply with all applicable federal and state law,
including but not limited to the statutes and regulations incorporated by
reference below in Sections D, G, and H, and applicable sections of the
state plan and waiver in its provision of services as the Mental Health
Plan. The 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 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
contract, the Contractor shall comply with the federal or state law or
regulation and the conflicting Contract provision shall no longer be in
effect.
C. The 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 the
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;
County of Fresno
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Exhibit E
ADDITIONAL PROVISIONS
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;
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.
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Exhibit E
ADDITIONAL PROVISIONS
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), the 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 the 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, the
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 work was to be performed after the date the legal
authority ended, the payment for that work should be returned to
DHCS. However, if the 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 the Contractor, the
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.
DHCS will attempt to provide Contractor with timely notice of the loss of
program 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
County of Fresno
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Exhibit E
ADDITIONAL PROVISIONS
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
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) §438.106 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
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Exhibit E
ADDITIONAL PROVISIONS
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
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:
The Contractor shall comply with all State and federal statutes and
regulations, the terms of this Agreement, BHINs, and any other applicable
authorities. In the event of a conflict between the terms of this Agreement
and a State or federal statute or regulation, or a BHIN, the Contractor shall
adhere to the applicable statute, regulation or BHIN.
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Exhibit E
ADDITIONAL PROVISIONS
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 §§ 14059.5 and 14184.402
3) Welf. & Inst. Code §§ 14680-14685.1
4) Welf. & Inst. Code §§ 14700-14727
5) 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
6) Cal. Code Regs., tit. 9, § 1810.100 et. seq. — Medi-Cal Specialty
Mental Health Services, except for those regulations that are
superseded by BHINs
7) Cal. Code Regs., tit. 22, §§ 50951 and 50953
8) Cal. Code Regs., tit. 22, §§ 51014.1 and 51014.2
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Exhibit E — Attachment 1
DEFINITIONS
1. The following definitions and the definitions contained in Cal. Code Regs., tit. 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. Code Regs., tit. 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 «Contractor Name».
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.
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
County of Fresno
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Exhibit E — Attachment 1
DEFINITIONS
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
O. "Homelessness" means The beneficiary meets the definition established in
section 11434a of the federal McKinney-Vento Homeless Assistance
Act.15 Specifically, this includes (A) individuals who lack a fixed, regular,
and adequate nighttime residence (within the meaning of section 103(a)(1)
of the Act); and (B) includes (i) children and youths who are sharing the
housing of other persons due to loss of housing, economic hardship, or a
similar reason; are living in motels, hotels, trailer parks, or camping
grounds due to the lack of alternative adequate accommodations; are
living in emergency or transitional shelters; or are abandoned in hospitals;
(ii) children and youths who have a primary nighttime residence that is a
public or private place not designed for or ordinarily used as a regular
sleeping accommodation for human beings (within the meaning of section
103(a)(2)(C)); (iii) children and youths who are living in cars, parks, public
spaces, abandoned buildings, substandard housing, bus or train stations,
or similar settings; and (iv) migratory children (as such term is defined in
section 1309 of the Elementary and Secondary Education Act of 1965)
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Exhibit E — Attachment 1
DEFINITIONS
who qualify as homeless for the purposes of this subtitle because the
children are living in circumstances described in clauses (i) through (iii).
P. Indian Health Care Provider (IHCP) means a health care program operated by
the IHS ("IHS facility"), an Indian Tribe, a Tribal Organization, or Urban Indian
Organization (otherwise known as an I/T/U) as those terms are defined in section
4 of the Indian Health Care Improvement Act (25 U.S.C. § 1603).
Q. "Involvement in child welfare" means the beneficiary has an open child
welfare services case, or the beneficiary is determined by a child welfare
services agency to be at imminent risk of entering foster care but able to
safely remain in their home or kinship placement with the provision of
services under a prevention plan, or the beneficiary is a child whose
adoption or guardianship occurred through the child welfare system. A
child has an open child welfare services case if: a) the child is in foster
care or in out of home care, including both court-ordered and by voluntary
agreement; or b) the child has a family maintenance case (pre-placement
or post-reunification), including both court-ordered and by voluntary
agreement. A child can have involvement in child welfare whether the
child remains in the home or is placed out of the home.
R. "Juvenile justice involvement" means the beneficiary (1) has ever been
detained or committed to a juvenile justice facility, or (2) is currently under
supervision by the juvenile delinquency court and/or a juvenile probation
agency. Beneficiaries who have ever been in custody and held
involuntarily through operation of law enforcement authorities in a juvenile
justice facility, including youth correctional institutions, juvenile detention
facilities, juvenile justice centers, and other settings such as boot camps,
ranches, and forestry/conservation camps, are included in the "juvenile
justice involvement" definition. Beneficiaries on probation, who have been
released home or detained/placed in foster care pending or post-
adjudication, under probation or court supervision, participating in juvenile
drug court or other diversion programs, and who are otherwise under
supervision by the juvenile delinquency court and/or a juvenile probation
agency also meet the "juvenile justice involvement" criteria.
S. "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
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Exhibit E — Attachment 1
DEFINITIONS
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 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)
T. "Medically necessary" or "medical necessity" has the same meaning as
set forth in Welfare and Institutions Code section 14059.5. For individuals
21 years of age or older, a service is "medically necessary" or a "medical
necessity" when it is reasonable and necessary to protect life, to prevent
significant illness or significant disability, or to alleviate severe pain. For
individuals under 21 years of age, a service is "medically necessary" or a
"medical necessity" if the service meets the standards set forth in Section
1396d(r)(5) of Title 42 of the United States Code.
U. 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)
V. "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.)
W. "Out-of-plan provider" has the same meaning as out-of-network provider.
X. "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)
Y. "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
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Exhibit E — Attachment 1
DEFINITIONS
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.
Z. "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.
AA. "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)
BB. "Rehabilitation" means a recovery or resiliency focused service activity
which addresses a mental health need. 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.)
CC. "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
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Exhibit E — Attachment 1
DEFINITIONS
multiagency site at which specialty mental health services are delivered by
no more than two employees or contractors of the provider.
DD. "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 Medical Education,
the American Medical Association, or the American Osteopathic
Association. (Cal. Code Regs., tit. 9 § 623.)
EE. "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.
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Exhibit E — Attachment 2
SERVICE DEFINITIONS
1. The Contractor shall provide, or arrange and pay for, the following covered
specialty mental health services to beneficiaries of Fresno County. Services shall
be provided as medically necessary 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.
2) 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.
3) 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.
4) 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. Collateral may include, but is not
limited 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). 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
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Exhibit E — Attachment 2
SERVICE DEFINITIONS
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.
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
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Exhibit E — Attachment 2
SERVICE DEFINITIONS
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
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 criteria to access SMHS. 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
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Exhibit E — Attachment 2
SERVICE DEFINITIONS
(ICPM), including the establishment of the Child and Family Team (CFT)
to ensure facilitation of a collaborative relationship among a child, their
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 child 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/child driven and culturally and linguistically competent
manner and that services and supports are guided by the needs of
the child;
2) Facilitates a collaborative relationship among the child, their family
and systems involved in providing services to the child;
3) Supports the parent/caregiver in meeting their child'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 to be served in their 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 build
skills necessary for successful functioning in the home and community
and improving the child's family's ability to help the child successfully
function in the home and community. IHBS services are provided 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, treatment plan, 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 the access criteria for
SMHS.
L. Therapeutic Behavioral Services (TBS) are intensive, individualized, short-
term outpatient treatment interventions for beneficiaries up to age 21 .
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Exhibit E — Attachment 2
SERVICE DEFINITIONS
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.
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 activities (plan
development, rehabilitation and collateral) to children 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. The TFC parent will provide trauma informed interventions that are
medically necessary for the child. TFC is intended for children 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 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. 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 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
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Exhibit E — Attachment 2
SERVICE DEFINITIONS
include professional services, which are billed separately from the
FFS/MC inpatient hospital services via the SD/MC claiming system.
O. 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.
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Exhibit F
Privacy and Security Provisions
1. This Agreement has been determined to constitute a business associate relationship under the Health
Insurance Portability and Accountability Act and its implementing privacy and security regulations at 45
Code of Federal Regulations, Parts 160 and 164 (collectively "HIPAX) only to the extent that Contractor
performs functions or activities on behalf of the Department pursuant to this Agreement that are described
in the definition of"business associate", including, but not limited to, utilization review, quality assurance, or
benefit management.
2. The term "Agreement" as used in this document refers to and includes both this Privacy and Security
Provisions and the contract to which this Privacy and Security Provisions is attached as an exhibit.
3. For purposes of this Agreement, the term "Business Associate" shall have the same meaning as set forth in
45 CFR section 160.103.
4. The Department of Health Care Services (DHCS) intends that Contractor may create, receive, maintain,
transmit or aggregate certain information pursuant to the terms of this Agreement, some of which information
may constitute Protected Health Information (PHI) and/or confidential information protected by Federal
and/or state laws.
4.1 As used in this Agreement and unless otherwise stated, the term "PHI" refers to and includes both "PHI"
as defined at 45 CFR section 160.103 and Personal Information (PI) as defined in the Information
Practices Act at California Civil Code section 1798.3(a). PHI includes information in any form, including
paper, oral, and electronic. The term PHI, as used in this exhibit, shall mean PHI accessed by Contractor
in a database maintained by DHCS, received by Contractor from the Department, or acquired, or created
by Contractor in connection with performing the functions, activities, and services on behalf of DHCS as
specified in this Agreement.
4.2 As used in this Agreement, the term "confidential information" refers to information not otherwise defined
as PHI in Section 4.1 of this Agreement, but to which state and/or federal privacy and/or security
protections apply.
5. Contractor, on DHCS's behalf, provides services or arranges, performs or assists in the performance of
functions or activities on behalf of DHCS, and may create, receive, maintain, transmit, aggregate, use or
disclose PHI (collectively, "use or disclose PHI") in order to fulfill Contractor's obligations under this
Agreement. DHCS and Contractor are each a party to this Agreement and are referred to, collectively, as the
"parties."
6. The terms used in this Agreement, but not otherwise defined, shall have the same meanings as those terms
in HIPAA. Any reference to statutory or regulatory language shall be to such language as in effect or as
amended.
7. Permitted Uses and Disclosures of PHI by Contractor. Except as otherwise indicated in this Agreement,
Contractor may use or disclose PHI, inclusive of de-identified data derived from such PHI, only to perform
functions, activities or services specified in this Agreement on behalf of DHCS, provided that such use or
disclosure would not violate HIPAA or other applicable laws if done by DHCS.
7.1 Specific Use and Disclosure Provisions. Except as otherwise indicated in this Agreement, Contractor
may use and disclose PHI if necessary for the proper management and administration of the Contractor
or to carry out the legal responsibilities of the Contractor. Contractor may disclose PHI for this purpose
if the disclosure is required by law, or if the Contractor obtains reasonable assurances from the person
to whom the information is disclosed that it will be held confidentially and used or further disclosed only
as required by law or for the purposes for which it was disclosed to the person, and the person notifies
the Contractor of any instances of which it is aware that the confidentiality of the information has been
breached.
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Exhibit F
Privacy and Security Provisions
8. Compliance with Other Applicable Law
8.1 To the extent that other state and/or federal laws provide additional, stricter and/or more protective
(collectively, more protective) privacy and/or security protections to PHI or other confidential information
covered under this Agreement beyond those provided through HIPAA, Contractor agrees:
8.1.1 To comply with the more protective of the privacy and security standards set forth in applicable state
or federal laws to the extent such standards provide a greater degree of protection and security than
HIPAA or are otherwise more favorable to the individuals whose information is concerned; and
8.1.2 To treat any violation of such additional and/or more protective standards as a breach or security
incident, as appropriate, pursuant to Section 17 of this Agreement.
8.2 Examples of laws that provide additional and/or stricter privacy protections to certain types of PHI
and/or confidential information, as defined in Section 4. of this Agreement, include, but are not limited
to the Information Practices Act, California Civil Code sections 1798-1798.78, Confidentiality of
Alcohol and Drug Abuse Patient Records, 42 CFR Part 2,Welfare and Institutions Code section 5328,
and California Health and Safety Code section 11845.5.
8.3 If Contractor is a Qualified Service Organization (QSO) as defined in 42 CFR section 2.11, Contractor
agrees to be bound by and comply with subdivisions (2)(i) and (2)(ii) under the definition of QSO in
42 CFR section 2.11.
9. Additional Responsibilities of Contractor
9.1 Nondisclosure. Contractor shall not use or disclose PHI or other confidential information other than as
permitted or required by this Agreement or as required by law.
9.2 Safeguards and Security.
9.2.1 Contractor shall use safeguards that reasonably and appropriately protect the confidentiality,
integrity, and availability of PHI and other confidential data and comply, where applicable, with
subpart C of 45 CFR Part 164 with respect to electronic protected health information, to prevent
use or disclosure of the information other than as provided for by this Agreement. Such
safeguards shall be based on applicable Federal Information Processing Standards (FIPS)
Publication 199 protection levels.
9.2.2 Contractor shall, at a minimum, utilize a National Institute of Standards and Technology Special
Publication (NIST SP) 800-53 compliant security framework when selecting and implementing
its security controls and shall maintain continuous compliance with NIST SP 800-53 as it may
be updated from time to time. The current version of NIST SP 800-53, Revision 5, is available
online at https://csrc.nist.gov/publications/detail/sp/800-53/rev-5/final; updates will be available
online at https://csrc.nist.gov/publications/sp800.
9.2.3 Contractor shall employ FIPS 140-2 validated encryption of PHI at rest and in motion unless
Contractor determines it is not reasonable and appropriate to do so based upon a risk
assessment, and equivalent alternative measures are in place and documented as such. FIPS
140-2 validation can be determined online at https://csrc.nist.gov/projects/cryptographic-module-
validation-program/validated-modules/search, with information about the Cryptographic Module
Validation Program under FIPS 140-2 available online at
https://csrc.nist.gov/Projects/cryptographic-module-validation-program/fips-140-2. In addition,
Contractor shall maintain, at a minimum, the most current industry standards for transmission
and storage of PHI and other confidential information.
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Exhibit F
Privacy and Security Provisions
9.2.4 Contractor shall apply security patches and upgrades, and keep virus software up-to-date, on all
systems on which PHI and other confidential information may be used.
9.2.5 Contractor shall ensure that all members of its workforce with access to PHI and/or other
confidential information sign a confidentiality statement prior to access to such data. The
statement must be renewed annually.
9.2.6 Contractor shall identify the security official who is responsible for the development and
implementation of the policies and procedures required by 45 CFR Part 164, Subpart C.
9.3 Contractor's Agent. Contractor shall ensure that any agents, subcontractors, subawardees, vendors
or others (collectively, "agents") that use or disclose PHI and/or confidential information on behalf of
Contractor agree to the same restrictions and conditions that apply to Contractor with respect to such
PHI and/or confidential information.
10. Mitigation of Harmful Effects. Contractor shall mitigate, to the extent practicable, any harmful effect that is
known to Contractor of a use or disclosure of PHI and other confidential information in violation of the
requirements of this Agreement.
11. Access to PHI. Contractor shall make PHI available in accordance with 45 CFR section 164.524.
12. Amendment of PHI. Contractor shall make PHI available for amendment and incorporate any amendments
to protected health information in accordance with 45 CFR section 164.526.
13. Accounting for Disclosures. Contractor shall make available the information required to provide an
accounting of disclosures in accordance with 45 CFR section 164.528.
14. Compliance with DHCS Obligations. To the extent Contractor is to carry out an obligation of DHCS under
45 CFR Part 164, Subpart E, comply with the requirements of the subpart that apply to DHCS in the
performance of such obligation.
15. Access to Practices, Books and Records. Contractor shall make its internal practices, books, and records
relating to the use and disclosure of PHI on behalf of DHCS available to DHCS upon reasonable request,
and to the federal Secretary of Health and Human Services for purposes of determining DHCS' compliance
with 45 CFR Part 164, Subpart E.
16. Return or Destroy PHI on Termination; Survival. At termination of this Agreement and any successor
agreements, if feasible, Contractor shall return or destroy all PHI and other confidential information received
from, or created or received by Contractor on behalf of, DHCS that Contractor still maintains in any form and
retain no copies of such information. If return or destruction is not feasible, Contractor shall notify DHCS of
the conditions that make the return or destruction infeasible, and DHCS and Contractor shall determine the
terms and conditions under which Contractor may retain the PHI. If such return or destruction is not feasible,
Contractor shall extend the protections of this Agreement to the information and limit further uses and
disclosures to those purposes that make the return or destruction of the information infeasible.
17. Breaches and Security Incidents. Contractor shall implement reasonable systems for the
discovery and prompt reporting of any breach or security incident, and take the following steps:
17.1 Notice to DHCS.
17.1.1 Contractor shall notify DHCS within 24 hours by email (or by telephone if Contractor is
unable to email DHCS) of the discovery of:
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Exhibit F
Privacy and Security Provisions
17.1.1.1 Unsecured PHI if the PHI is reasonably believed to have been accessed or
acquired by an unauthorized person;
17.1.1.2 Any suspected security incident which risks unauthorized access to PHI and/or
other confidential information;
17.1.1.3 Any intrusion or unauthorized access, use or disclosure of PHI in violation of this
Agreement; or
17.1.1.4 Potential loss of confidential data affecting this Agreement.
17.1.2 Notice shall be provided to the DHCS Program Contract Manager (as applicable), the DHCS
Privacy Office, and the DHCS Information Security Office (collectively, "DHCS Contacts")
using the DHCS Contact Information at Section 17.6. below.
Notice shall be made using the current DHCS "Privacy Incident Reporting Form" ("PIR Form";
the initial notice of a security incident or breach that is submitted is referred to as an "Initial
PIR Form") and shall include all information known at the time the incident is reported. The
form is available online at
https://www.dhcs.ca.gov/formsandpubs/laws/priv/Documents/Privacy-Incident-Report-PIR.Pdf .
Upon discovery of a breach or suspected security incident, intrusion or unauthorized access,
use or disclosure of PHI, Contractor shall take:
17.1.2.1 Prompt action to mitigate any risks or damages involved with the security incident or
breach; and
17.1.2.2 Any action pertaining to such unauthorized disclosure required by applicable Federal
and State law.
17.2 Investigation. Contractor shall immediately investigate such security incident or confidential breach.
17.3 Complete Report. To provide a complete report of the investigation to the DHCS contacts within ten
(10) working days of the discovery of the security incident or breach. This "Final PIR" must include
any applicable additional information not included in the Initial Form. The Final PIR Form shall include
an assessment of all known factors relevant to a determination of whether a breach occurred under
HIPAA and other applicable federal and state laws. The report shall also include a full, detailed
corrective action plan, including its implementation date and information on mitigation measures
taken to halt and/or contain the improper use or disclosure. If DHCS requests information in addition
to that requested through the PIR form, Contractor shall make reasonable efforts to provide DHCS
with such information. A"Supplemental PIR" may be used to submit revised or additional information
after the Final PIR is submitted. DHCS will review and approve or disapprove Contractor's
determination of whether a breach occurred, whether the security incident or breach is reportable to
the appropriate entities, if individual notifications are required, and Contractor's corrective action plan.
17.3.1 If Contractor does not complete a Final PIR within the ten (10) working day timeframe,
Contractor shall request approval from DHCS within the ten (10) working day timeframe of a
new submission timeframe for the Final PIR.
17.4 Notification of Individuals. If the cause of a breach is attributable to Contractor or its agents,
Contractor shall notify individuals accordingly and shall pay all costs of such notifications, as well as
all costs associated with the breach. The notifications shall comply with applicable federal and state
law. DHCS shall approve the time, manner and content of any such notifications and their review and
approval must be obtained before the notifications are made.
County of Fresno
22-20101
Page 5 of 6
Exhibit F
Privacy and Security Provisions
17.5 Responsibility for Reporting of Breaches to Entities Other than DHCS. If the cause of a breach
of PHI is attributable to Contractor or its subcontractors, Contractor is responsible for all required
reporting of the breach as required by applicable federal and state law.
17.6 DHCS Contact Information. To direct communications to the above referenced DHCS staff, the
Contractor shall initiate contact as indicated here. DHCS reserves the right to make changes to the
contact information below by giving written notice to Contractor. These changes shall not require
an amendment to this Agreement.
DHCS Program DHCS Privacy Office DHCS Information Security Office
Contract Manager
See the Scope of Work Privacy Office Information Security Office
exhibit for Program c/o: Office of HIPAA Compliance DHCS Information Security Office
Contract Manager Department of Health Care Services P.O. Box 997413, MS 6400
information. P.O. Box 997413, MS 4722 Sacramento, CA 95899-7413
Sacramento, CA 95899-7413
Email: incidents(o-)-dhcs.ca.gov
Email: incidents(a-dhcs.ca.gov
Telephone: (916)445-4646
18. Responsibility of DHCS. DHCS agrees to not request the Contractor to use or disclose PHI in any manner
that would not be permissible under HIPAA and/or other applicable federal and/or state law.
19. Audits, Inspection and Enforcement
19.1 From time to time, DHCS may inspect the facilities, systems, books and records of Contractor to monitor
compliance with this Agreement. Contractor shall promptly remedy any violation of this Agreement
and shall certify the same to the DHCS Privacy Officer in writing. Whether or how DHCS exercises
this provision shall not in any respect relieve Contractor of its responsibility to comply with this
Agreement.
19.2 If Contractor is the subject of an audit, compliance review, investigation or any proceeding that is related
to the performance of its obligations pursuant to this Agreement, or is the subject of any judicial or
administrative proceeding alleging a violation of HIPAA, Contractor shall promptly notify DHCS unless
it is legally prohibited from doing so.
20. Termination
20.1 Termination for Cause. Upon DHCS' knowledge of a violation of this Agreement by Contractor,
DHCS may in its discretion:
20.1.1 Provide an opportunity for Contractor to cure the violation and terminate this Agreement if
Contractor does not do so within the time specified by DHCS; or
20.1.2 Terminate this Agreement if Contractor has violated a material term of this Agreement.
20.2 Judicial or Administrative Proceedings. DHCS may terminate this Agreement if Contractor is
found to have violated HIPAA, or stipulates or consents to any such conclusion, in any judicial or
administrative proceeding.
21. Miscellaneous Provisions
County of Fresno
22-20101
Page 6 of 6
Exhibit F
Privacy and Security Provisions
21.1 Disclaimer. DHCS makes no warranty or representation that compliance by Contractor with this
Agreement will satisfy Contractor's business needs or compliance obligations. Contractor is solely
responsible for all decisions made by Contractor regarding the safeguarding of PHI and other
confidential information.
21.2. Amendment.
21.2.1 Any provision of this Agreement which is in conflict with current or future applicable Federal or
State laws is hereby amended to conform to the provisions of those laws. Such amendment of
this Agreement shall be effective on the effective date of the laws necessitating it, and shall be
binding on the parties even though such amendment may not have been reduced to writing and
formally agreed upon and executed by the parties.
21.2.2 Failure by Contractor to take necessary actions required by amendments to this Agreement
under Section 21.2.1 shall constitute a material violation of this Agreement.
21.3 Assistance in Litigation or Administrative Proceedings. Contractor shall make itself and its
employees and agents available to DHCS at no cost to DHCS to testify as witnesses, or otherwise,
in the event of litigation or administrative proceedings being commenced against DHCS, its directors,
officers and/or employees based upon claimed violation of HIPAA, which involve inactions or actions
by the Contractor.
21.4 No Third-Party Beneficiaries. Nothing in this Agreement is intended to or shall confer, upon any
third person any rights or remedies whatsoever.
21.5 Interpretation. The terms and conditions in this Agreement shall be interpreted as broadly as
necessary to implement and comply with HIPAA and other applicable laws.
21.6 No Waiver of Obligations. No change, waiver or discharge of any liability or obligation hereunder
on any one or more occasions shall be deemed a waiver of performance of any continuing or other
obligation, or shall prohibit enforcement of any obligation, on any other occasion.
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:
BERNIi EIDEL
Clerk o E E. Board
L'1r® Clerk of the Board of Supervisors
County of Fresno,State of California
Printed Name and Title of Person Signing By Deputy
Brain Pacheco Chairman to the Board of Supervisors of the County of Fresno
Date Executed Executed in the County of
/d — C.C2, —C9 �;L 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 CODE/WORKERS' 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.
Accounting String
FUND/SUBCLASS: 0001/10000
ORG: 56309999
ACCOUNTS: 4383,4402,4404,4408,4412, 4428