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Home My WebLink AboutAgreement A-23-298 Amendment II to Agreements with CCFMG.pdf Agreement No. 23-298 1 AMENDMENT II TO AGREEMENT 2 THIS AMENDMENT, hereinafter referred to as Amendment Il, is made and entered into this 20th 3 day of June , 2023, by and between the COUNTY OF FRESNO, a Political Subdivision of the 4 State of California, hereinafter referred to as "COUNTY", and Central California Faculty Medical Group, 5 Inc. (CCFMG), a California professional corporation, whose address is 2625 East Divisadero Street, 6 Fresno, California 93721, hereinafter referred to as "CONTRACTOR". Reference in this Agreement to 7 party or"parties" shall be understood to refer to COUNTY and CONTRACTOR, unless otherwise 8 specified. 9 WHEREAS, the parties entered into that certain Agreement, identified as COUNTY Agreement No. 10 18-234, effective May 1, 2018 and Amendment I, identified as COUNTY Agreement No. 22-023, effective 11 January 18, 2022, collectively referred to as the "Agreement," whereby CONTRACTOR agreed to provide 12 licensed psychiatrists and nurse practitioners to County's Department of Behavioral Health (DBH)for the 13 provision of psychiatric services to individuals living in Fresno County, as well as additional services 14 required by COUNTY. 15 NOW, THEREFORE, for good and valuable consideration, the receipt and adequacy of which is 16 hereby acknowledged, the parties agree as follows: 17 1. That the existing COUNTY Agreement No. 18-234, Section Two (2) on Page Two (2), 18 Line Three (3), beginning with the word "This" and ending on Page Two (2), Line Nine (9), with the 19 word "performance" be replaced as follows: 20 "This Agreement shall become effective on the 1st day of May, 2018 and shall terminate 21 on the 30th day of June, 2024. 22 This Agreement may be extended for one (1) additional twelve (12) month period upon 23 written approval of both parties not later than sixty (60) days prior to the close of the current 24 Agreement term. COUNTY's DBH Director or designee is authorized to execute such written approval 25 on behalf of COUNTY based on CONTRACTOR's satisfactory performance." 26 2. That the existing COUNTY Agreement No. 22-023, Section Three (3) on Page One (1), 27 Line Twenty-Eight (28), beginning with the word "The" and ending on Page Two (2), Line Twenty-One 28 (21), with the word "Agreement" be replaced as follows: 1 1 "The maximum amount payable to CONTRACTOR for the ramp up period of May 1, 2 2018 through June 30, 2018 shall not exceed Three Hundred Thirty-Six Thousand Two Hundred Fifty- 3 Three and No/100 Dollars ($336,253.00). 4 The maximum amount payable to CONTRACTOR for the initial operational period of 5 July 1, 2018 through June 30, 2019 shall not exceed Three Million Eight Hundred Eighty-One 6 Thousand Two Hundred Sixty and No/100 Dollars ($3,881,260.00). 7 The maximum amount payable to CONTRACTOR for the period of July 1, 2019 through 8 June 30, 2020 shall not exceed Six Million Four Hundred Ninety-Seven Thousand Two Hundred 9 Eighty-Eight and No/100 Dollars ($6,497,288.00). 10 The maximum amount payable to CONTRACTOR for the period of July 1, 2020 through 11 June 30, 2021 shall not exceed Nine Million Four Hundred Eighty-Five Thousand Seven Hundred 12 Sixty-Three and No/100 Dollars ($9,485,763.00). 13 The maximum amount payable to CONTRACTOR for the period of July 1, 2021 through 14 June 30, 2022 shall not exceed Ten Million Five Hundred Eighty-Seven Thousand Five Hundred 15 Thirty-Four and No/100 Dollars ($10,587,534.00). 16 The maximum amount payable to CONTRACTOR for the period of July 1, 2022 through 17 June 30, 2023 shall not exceed Twelve Million One Hundred Fifty-One Thousand One Hundred Forty- 18 Two and No/100 Dollars ($12,151,142.00). 19 The maximum amount payable to CONTRACTOR for the period of July 1, 2023 through 20 June 30, 2024 shall not exceed Twelve Million One Hundred Fifty-One Thousand One Hundred Forty- 21 Two and No/100 Dollars ($12,151,142.00). 22 The maximum amount payable to CONTRACTOR for the period of July 1, 2024 through 23 June 30, 2025 shall not exceed Twelve Million One Hundred Fifty-One Thousand One Hundred Forty- 24 Two and No/100 Dollars ($1,151,142.00). 25 In no event shall the maximum contract amount for all the services provided by the 26 CONTRACTOR to COUNTY under the terms and conditions of this Agreement be in excess of Sixty- 27 Seven Million Two Hundred Forty-One Thousand Five Hundred Twenty-Four and No/100 Dollars 28 ($67,241,524.00) during the total term of this Agreement." 2 1 3. That the existing COUNTY Agreement No. 22-023, Section Five (5) on Page Seven (7), 2 Line Seven (7), beginning with the letter "A" and ending on Page Nine (9), Line Seven (7), with the 3 word "requirements" include the following language as follows: 4 "I. Specialty Mental Health Services Claiming 5 Contractor shall enter claims data into the County's billing and transactional 6 database system by the fifteenth (15th) of every month for actual services rendered in the previous 7 month. Contractor shall use Current Procedural Terminology (CPT) or Healthcare Common Procedure 8 Coding System (HCPCS) codes, as provided in the DHCS Billing Manual available at 9 https://www.dhcs.ca.gov/services/MH/Pages/MedCCC-Library.aspx, as from time to time amended. 10 Claims shall be complete and accurate and must include all required information regarding the claimed 11 services." 12 4. That the existing COUNTY Agreement No. 22-023, Section Sixteen (16) on Page 13 Sixteen (16), Line Thirteen (13), beginning with the word "CONTRACTOR" and ending on Page 14 Sixteen (16), Line Twenty-One (21), with the word "designee" be replaced as follows: 15 "CONTRACTOR recognizes that COUNTY operates its mental health programs under 16 an agreement with the State of California Department Health Care Services, and that under said 17 agreement the State imposes certain requirements on COUNTY and its subcontractors. 18 CONTRACTOR shall adhere to all State requirements, including those identified in Revised Exhibit E 19 "Behavioral Health Requirements", attached hereto and by this reference incorporated herein and 20 made part of this Agreement. CONTRACTOR shall also file an incident report for all incidents involving 21 clients, following the Protocol and using the Worksheet identified in Exhibit F, attached hereto and by 22 this reference incorporated herein and made part of this Agreement or a protocol and worksheet 23 presented by CONTRACTOR that is accepted by COUNTY's DBH Director or designee. 24 CONTRACTOR shall comply with all CalAIM initiatives set forth by DHCS and DBH." 25 5. That all references in the existing Agreement No. 22-023 to "Revised Exhibit B" shall be 26 deemed references to "Revised Exhibit B-1", which is attached and incorporated by this reference. 27 6. That all references in the existing Agreement to "Exhibit D" shall be deemed references to 28 "Revised Exhibit D", which is attached and incorporated by this reference. 3 1 7. That all references in the existing Agreement to "Exhibit E" shall be deemed references to 2 "Revised Exhibit E", which is attached and incorporated by this reference. 3 8. The parties agree that this Amendment II is sufficient to amend the Agreement; and that 4 upon execution of the Agreement, Amendment I, and Amendment II together shall be considered the 5 Agreement. 6 9. The Agreement, as hereby amended, is ratified and continued. All provisions, terms, 7 covenants, conditions, and promises contained in the Agreement and not amended herein shall remain in 8 full force and effect. This Amendment II shall be effective July 1, 2023. 9 N 10 N 11 N 12 N 13 N 14 N 15 N 16 N 17 N 18 N 19 N 20 N 21 N 22 N 23 N 24 N 25 N 26 N 27 N 28 N 4 1 IN WITNESS WHEREOF, the parties hereto have executed this Amendment III to 2 Agreement as of the date first above set forth. 3 4 5 Please see attached signatures COUNTY OF FRESNO 6 7 ;> I Q i ero, 8 C° ' ma the Board of Supervisors of 9 the County of Fresno 10 11 12 13 ATTEST: 14 Bernice E. Seidel Clerk of the Board of Supervisors 15 County of Fresno, State of California 16 17 By: Deputy 18 19 20 21 22 23 24 FOR ACCOUNTING USE ONLY: Fund/Subclass: 0001/10000 25 ORG No.: 56302920 56302246 26 Account No.: 7295/0 27 28 5 ii DocuSign Envelope ID:CFB45206-F62A-4272-9DD7-CF6E4A7CCD27 1 IN WITNESS WHEREOF, the parties hereto have executed this Amendment II to 2 Agreement No. 18-234 as of the date first above set forth. 3 4 CENTRAL CALIFORNIA FACULTY MEDICAL 5 GROUP, INC. (CCFMG) 6 DocuSlgned by: 7 By: 8 9 Print Name: Joyce Fields-Keene, MPA 10 Title: Chief Executive Officer 11 Chairman of Board, or President or any Vice President 12 Date: 05/25/2023 13 14 DocuSlgned�by::��,¢ 15 By: 16 17 Print Name: Devin Nugent 18 19 Title: Chief Administrative Officer Secretary(of Corporation), or any Assistant Secretary, 2 0 or Chief Financial Officer or any Assistant Treasurer 21 Date: 05/26/2023 22 23 24 Mailing Address: 114 W. 7th Street, Suite 900 25 Austin, TX 78701 26 phone No.: (888) 285-2269 27 Contact: Thomas Milam, MD 28 1 — COUNTY OF FRESNO Fresno,CA Revised Exhibit B-1 Page 1 of 16 CCFMG Fiscal Year(FY)2023-2024 PROGRAM EXPENSES 1000:DIRECT SALARIES&BENEFITS Direct Employee Salaries Acct# Administrative Position FTE Admin Program Total 1101 Medical Director-Dr.Tran 0.90 $ 429,418 $ 429,418 1102 Executive Assistant-Shelley McNiff 1.00 63,949 63,949 1103 Retention Bonus 390,000 390,000 1104 Relocation Cost 360,000 360,000 1105 Loan Repayment Cost 500,000 500,000 1106 - - 1107 - - 1108 - - 1109 - - 1110 - 1111 - - 1112 - - 1113 - - 1114 - - 1115 - - Direct Personnel Admin Salaries Subtotal 1.90 $ 1,743,367 $ - $ 1,743,367 Acct# Program Position FTE Admin Program Total 1116 Medical Director-Dr.Tran 0.10 $ 47,713 $ 47,713 1117 Interim Assistant Chief Peds-Dr.Cheema 1.00 $ 381,480 $ 381,480 1118 Psychiatrist-Dr. Benavidez 1.00 364,140 364,140 1119 Psychiatrist-Dr. Domanska 1.00 364,140 364,140 1120 Psychiatrist-Dr.Chavira 1.00 364,140 364,140 1121 Psychiatrist-Dr. Liang 1.00 357,000 357,000 1122 Psychiatrist-Dr. Robles 1.00 357,000 357,000 1123 Psychiatrist 0.92 328,440 328,440 1124 Psychiatrist Chart Review 0.08 28,560 28,560 1125 Psychiatrist 1.00 357,000 357,000 1126 Psychiatrist 1.00 357,000 357,000 1127 Psychiatrist 1.00 357,000 357,000 1128 Psychiatrist 1.00 357,000 357,000 1129 Psychiatrist 1.00 357,000 357,000 1130 Psychiatrist 1.00 357,000 357,000 1131 Psychiatrist 1.00 357,000 357,000 1132 PharmacistD 1.00 148,000 148,000 1133 Nurse Practitioner-Hope Lo 1.00 163,200 163,200 1134 Nurse Practitioner 1.00 163,200 163,200 1135 Nurse Practitioner 1.00 163,200 163,200 1136 Nurse Practitioner 1.00 163,200 163,200 1137 Nurse Practitioner 1.00 163,200 163,200 1138 Nurse Practitioner 1.00 163,200 163,200 1139 Nurse Practitioner 1.00 163,200 163,200 1140 Nurse Practitioner 1.00 163,200 163,200 1141 Nurse Practitioner 1.00 163,200 163,200 1142 Nurse Practitioner 1.00 163,200 163,200 1143 Nurse Practitioner 1.00 163,200 163,200 Direct Personnel Program Salaries Subtotal 26.10 $ 7,034,813 $ 7,034,813 Admin Program Total Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Revised Exhibit B-1 Page 2 of 16 Direct Personnel Salaries Subtotall 28.00 1 $ 1,743,367 1 $ 7,034,813 1 $ 8,778,180 Direct Employee Benefits Acct# Description Admin Program Total 1201 Retirement $ 5,354 $ 187,135 $ 192,489 1202 Worker's Compensation 726 47,215 47,941 1203 Health Insurance 11,753 397,507 409,260 1204 Other(specify) Malpractice 478 91,040 91,518 1205 10ther(specify) - - - 1206 10ther(specify) - - - Direct Employee Benefits Subtotal: $ 18,311 $ 722,897 $ 741,208 Direct Payroll Taxes&Expenses: Acct# Description Admin Program Total 1301 OASDI $ 4,850 $ 238,162 $ 243,012 1302 FICA/MEDICARE 1,619 105,327 106,946 1303 SUI 262 6,402 6,664 1304 Other(specify) - - - 1305 10ther(specify) - - 1306 10ther(specify) - - - Direct Payroll Taxes&Expenses Subtotal: $ 6,731 $ 349,891 $ 356,622 DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total $ 1,768,409 $ 8,107,601 $ 9,876,010 DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program 18% 82% 2000: DIRECT CLIENT SUPPORT Acct# Line Item Description Amount 2001 Child Care $ - 2002 Client Housing Support - 2003 Client Transportation&Support - 2004 Clothing, Food,&Hygiene - 2005 Education Support - 2006 Employment Support - 2007 Household Items for Clients - 2008 Medication Supports - 2009 Program Supplies-Medical - 2010 Utility Vouchers - 2011 Other(specify) - 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) - 2015 10ther(specify) - 2016 10ther(specify) - DIRECT CLIENT CARE TOTAL $ - 3000:DIRECT OPERATING EXPENSES Acct# Line Item Description Amount 3001 Telephone $ 33,600 3002 Printing/Postage - 3003 Office,Household&Program Supplies - 3004 Advertising - 3005 Staff Development&Training - 3006 Staff Mileage - 3007 Subscriptions&Memberships - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Revised Exhibit B-1 Page 3 of 16 3008 Vehicle Maintenance - 3009 Other(Food) 21,480 3010 Other(Lodging) 36,400 3011 Other(Recruiting) 562,320 3012 Other(Airfare) 24,400 3013 Other(Rental Car) 10,200 DIRECT OPERATING EXPENSES TOTAL:1 $ 688,400 4000: DIRECT FACILITIES&EQUIPMENT Acct# Line Item Description Amount 4001 Building Maintenance $ - 4002 Rent/Lease Building - 4003 Rent/Lease Equipment - 4004 Rent/Lease Vehicles - 4005 Security - 4006 Utilities - 4007 Other(specify) - 4008 Other(specify) - 4009 Other(specify) - 4010 10ther(specify) - DIRECTFACILITIES/EQUIPMENTTOTAL: $ - 5000:DIRECT SPECIAL EXPENSES Acct# Line Item Description Amount 5001 Consultant(Network&Data Management) $ 1,800 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) - 5004 Translation Services - 5005 Other(specify) - 5006 Other(specify) - 5007 Other(specify) - 5008 Other(specify) - DIRECT SPECIAL EXPENSES TOTAL:1 $ 1,800 6000: INDIRECT EXPENSES Acct# Line Item Description Amount Administrative Overhead 6001 Use this line and only this line for approved indirect cost rate $ - Administrative Overhead 6002 Professional Liability Insurance - 6003 Accounting/Bookkeeping - 6004 External Audit - 6005 Insurance(Specify): - 6006 Payroll Services - 6007 Depreciation(Provider-Owned Equipment to be Used for Program Purposes) - 6008 Personnel(Indirect Salaries&Benefits) - 6009 Other(Administrative Overhead) $ 1,584,932 6010 Other(specify) - 6011 Other(specify) - 6012 Other(specify) - 6013 10ther(specify) - INDIRECT EXPENSES TOTAL $ 1,584,932 INDIRECT COST RATE 15.00% Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Revised Exhibit B-1 Page 4 of 16 7000:DIRECT FIXED ASSETS Acct# Line Item Description Amount 7001 Computer Equipment&Software $ - 7002 Copiers,Cell Phones,Tablets, Devices to Contain HIPAA Data - 7003 Furniture&Fixtures - 7004 Leasehold/Tenant/Building Improvements - 7005 Other Assets over$500 with Lifespan of 2 Years+ - 7006 Assets over$5,000/unit(Specify) - 7007 Other(specify) - 7008 Other(specify) - FIXED ASSETS EXPENSES TOTAL $ - TOTAL PROGRAM EXPENSES $ 12,151,142 PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) Acct# Line Item Description Service Units Rate Amount 8001 Mental Health Services 0 - $ - 8002 Case Management 0 - 8003 Crisis Services 0 - - 8004 Medication Support 0 - 8005 Collateral 0 - - 8006 Plan Development 0 - 8007 Assessment 0 - - 8008 Rehabilitation 0 - 8009 Other(Specify) 0 - 8010 10ther(Specify) 0 - Estimated Specialty Mental Health Services Billing Totals: 0 $ - Estimated%of Clients who are Medi-Cal Beneficiaries 77 Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries - Federal Financial Participation(FFP)% 1 0% MEDI-CAL FFP TOTAL $ - 8100-SUBSTANCE USE DISORDER FUNDS Acct# Line Item Description Amount 8101 Drug Medi-Cal $ - 8102 SABG $ - SUBSTANCE USE DISORDER FUNDS TOTAL $ - 8200-REALIGNMENT Acct# Line Item Description Amount 8201 lRealignment $ 12,151,142 REALIGNMENT TOTAL $ 12,151,142 8300-MENTAL HEALTH SERVICE ACT(MHSA) Acct# MHSA Component MHSA Program Name Amount 8301 CSS-Community Services&Supports $ - 8302 PEI-Prevention&Early Intervention - 8303 INN-Innovations - 8304 WET-Workforce Education&Training - 8305 JCFTN-Capital Facilities&Technology - MHSA TOTAL $ - 8400-OTHER REVENUE Acct# Line Item Description Amount Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Revised Exhibit B-1 Page 5 of 16 8401 Client Fees $ - 8402 Client Insurance - 8403 Grants(Specify) - 8404 Other(Specify) - 8405 Other(Specify) - OTHER REVENUE TOTAL $ - TOTAL PROGRAM FUNDING SOURCES: $ 12,151,142 NET PROGRAM COST: $ - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Revised Exhibit B-1 Page 6 of 16 CCFMG Fiscal Year(FY)2023-2024 Budget Narrative PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1000:DIRECT SALARIES&BENEFITS 9,876,010 Administrative Positions 1,743,367 1101 Medical Director-Dr.Tran 429,418 2%increase each July 1;Administrative responsibilities for Medical Director 1102 Executive Assistant-Shelley McNiff 63,949 2%increase each July 1;administrative support for Medical Director 1103 Retention Bonus 390,000 $30k per 8 vacant MDs and$15k per 10 vacant NPs.Paid in return for 3 years service 1104 Relocation Cost 360,000 $20k per 18 potentially vacant MD/NP positions base upon IRS guidelines;must show receipts 1105 Loan Repayment Cost 500,000 $50k per vacant MD(10) 1106 0 - 1107 0 1108 0 1109 0 1110 0 1111 0 1112 0 1113 0 1114 0 1115 O Program Positions 7,034,813 1116 Medical Director-Dr.Tran 47,713 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1117 Interim Assistant Chief Peds-Dr.Cheema 381,480 4%increase from previous year;will be working at 60%of this FTE;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties;some oversight of psychiatrists and nurse practitioners 1118 Psychiatrist-Dr.Benavidez 364,140 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1119 Psychiatrist-Dr.Domanska 364,140 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1120 Psychiatrist-Dr.Chavira 364,140 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1121 Psychiatrist-Dr.Hang 357,000 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1122 Psychiatrist-Dr.Robles 357,000 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1123 Psychiatrist 328,440 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties;split duties with Psychiatrist Chart Review(line 1124) 1124 Psychiatrist Chart Review 28,560 (Vacant)Medication monitoring;split duties for Psychiatrist(line 1123) 1125 Psychiatrist 357,000 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1126 Psychiatrist 357,000 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1127 Psychiatrist 357,000 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1128 Psychiatrist 357,000 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1129 Psychiatrist 357,000 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1130 Psychiatrist 357,000 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1131 Psychiatrist 357,000 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1132 PharmacistD 148,000 (Vacant)2%increase each July 1;clinical pharmacist,assess appropriateness/effectiveness/safety of all medications for patients enrolled in service, assist in disease state management 1133 Nurse Practitioner-Hope Lo 163,200 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1134 Nurse Practitioner 163,200 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1135 Nurse Practitioner 163,200 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1136 Nurse Practitioner 163,200 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1137 Nurse Practitioner 163,200 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1138 Nurse Practitioner 163,200 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1139 Nurse Practitioner 163,200 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties Fresno County Department of Behavioral Health Contract Budget Narrative Revised 217/2020 Revised Exhibit B-1 Page 7 of 16 PROGRAM EXPENSE ACCT#j LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1140 Nurse Practitioner 163,200 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1141 Nurse Practitioner 163,200 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1142 Nurse Practitioner 163,200 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1143 Nurse Practitioner 163,200 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties Direct Employee Benefits 741,208 1201 Retirement 192,489 1202 Worker's Compensation 47,941 1203 Health Insurance 409,260 1204 Other(specify)Malpractice 91,518 1205 Other(specify) - 1206 Other(specify) - Direct Payroll Taxes&Expenses: 356,622 1301 OASDI 243,012 1302 FICA/MEDICARE 106,946 1303 SUI 6,664 1304 Other(specify) - 1305 Other(specify) 1306 Other(specify) 2000:DIRECT CLIENT SUPPORT 2001 Child Care 2002 Client Housing Support 2003 Client Transportation&Support 2004 Clothing,Food,&Hygiene 2005 Education Support 2006 Employment Support 2007 Household Items for Clients 2008 Medication Supports 2009 Program Supplies-Medical 2010 Utility Vouchers 2011 Other(specify) 2012 Other(specify) 2013 Other(specify) 2014 Other(specify) 2015 Other(specify) 2016 1 Other(specify) 3000:DIRECT OPERATING EXPENSES 688,400 3001 Telephone 33,600 Phone charges @$100/month per FTE 3002 Printing/Postage - 3003 Office,Household&Program Supplies 3004 Advertising 3005 Staff Development&Training 3006 Staff Mileage 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance 3009 Other(Food) 21,480 per candidate estimate when coming onsite for interview+staff meals and candidate group meals at conference 3010 Other(Lodging) 36,400 per candidate estimate when coming onsite for interview+standard rate x number of conferences planned 3011 Other(Recruiting) 562,320 Recruiting charges from staffing agency($35K/MD and$22K/NP)+estimated conference fees and advertising costs 3012 Other(specify)Airfare 24,400 per candidate estimate when coming onsite for interview+$1200/person(flights+ baggage fees)x 8 planned conferences(added additional$400 for misc fees) 3013 1 Other(Rental Car) 1 10,200 1 per candidate estimate when coming onsite for interview 4000:DIRECT FACILITIES&EQUIPMENT - 4001 Building Maintenance 4002 Rent/Lease Building 4003 Rent/Lease Equipment 4004 Rent/Lease Vehicles 4005 Security 4006 Utilities 4007 Other(specify) 4008 Other(specify) 4009 Other(specify) 4010 1 Other(specify) Fresno County Department of Behavioral Health Contract Budget Narrative Revised 217/2020 Revised Exhibit B-1 Page 8 of 16 PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 5000:DIRECT SPECIAL EXPENSES 1,800 5001 Consultant(Network&Data Management) 1,800 3rd party IT services for network and data 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) 5004 Translation Services 5005 Other(specify) 5006 Other(specify) 5007 Other(specify) 5008 1 Other(specify) 6000:INDIRECT EXPENSES 1,584,932 6001 Administrative Overhead - 6002 Professional Liability Insurance 6003 Accounting/Bookkeeping 6004 External Audit 6005 Insurance(Specify): 6006 Payroll Services 6007 Depreciation(Provider-Owned Equipment to be Used 6008 Personnel(Indirect Salaries&Benefits) - 6009 Other(Administrative Overhead) 1,584,932 Expenses fund corporate expenses related to administration of provider employment, contract administration,financial review,and ongoing contract management. Administrative Overhead costs are 15%of total expenses. 6010 Other(specify) - 6011 Other(specify) 6012 Other(specify) 6013 1 Other(specify) 7000:DIRECT FIXED ASSETS 7001 Computer Equipment&Software 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA 7003 Furniture&Fixtures 7004 Leasehold/Tenant/Building Improvements 7005 Other Assets over$500 with Lifespan of 2 Years+ 7006 Assets over$5,000/unit(Specify) 7007 Other(specify) 7008 1 Other(specify) PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) PROVIDE DETAILS OF METHODOLOGY(IES)USED IN DETERMINING MEDI-CAL ACCT# LINE ITEM SERVICE RATES AND/OR SERVICE UNITS,IF APPLICABLE AND/OR AS REQUIRED BY THE RFP 8001 Mental Health Services 8002 Case Management 8003 Crisis Services 8004 Medication Support 8005 Collateral 8006 Plan Development 8007 Assessment 8008 Rehabilitation 8009 Other(Specify) 8010 Other(Specify) TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 12,151,142 TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 12,151,142 BUDGET CHECK: - Fresno County Department of Behavioral Health Contract Budget Narrative Revised 217/2020 Revised Exhibit B-1 Page 9 of 16 CCFMG Fiscal Year(FY)2024-25 PROGRAM EXPENSES 1000:DIRECT SALARIES&BENEFITS Direct Employee Salaries Acct# Administrative Position FTE Admin Program Total 1101 Medical Director-Dr.Tran 0.90 $ 438,007 $ 438,007 1102 Executive Assistant-Shelley McNiff 1.00 65,228 65,228 1103 Retention Bonus 390,000 390,000 1104 Relocation Cost 360,000 360,000 1105 Loan Repayment Cost 500,000 500,000 1106 - - 1107 - - 1108 - - 1109 - - 1110 - 1111 - - 1112 - - 1113 - - 1114 - - 1115 - - Direct Personnel Admin Salaries Subtotal 1.90 $ 1,753,235 $ - $ 1,753,235 Acct# Program Position FTE Admin Program Total 1116 Medical Director-Dr.Tran 0.10 $ 48,668 $ 48,668 1117 Interim Assistant Chief Peds-Dr.Cheema 0.60 $ 233,466 $ 233,466 1118 Psychiatrist-Dr. Benavidez 1.00 371,423 371,423 1119 Psychiatrist-Dr. Domaska 1.00 371,423 371,423 1120 Psychiatrist-Dr.Chavira 1.00 371,423 371,423 1121 Psychiatrist-Dr. Liang 1.00 364,140 364,140 1122 Psychiatrist-Dr. Robles 1.00 364,140 364,140 1123 Psychiatrist 0.92 335,009 335,009 1124 Psychiatrist Chart Review 0.08 29,131 29,131 1125 Psychiatrist 1.00 364,140 364,140 1126 Psychiatrist 1.00 364,140 364,140 1127 Psychiatrist 1.00 364,140 364,140 1128 Psychiatrist 1.00 364,140 364,140 1129 Psychiatrist 1.00 364,140 364,140 1130 Psychiatrist 1.00 364,140 364,140 1131 Psychiatrist 1.00 364,140 364,140 1132 PharmacistD 1.00 150,960 150,960 1133 Nurse Practitioner-Hope Lo 1.00 166,464 166,464 1134 Nurse Practitioner 1.00 166,464 166,464 1135 Nurse Practitioner 1.00 166,464 166,464 1136 Nurse Practitioner 1.00 166,464 166,464 1137 Nurse Practitioner 1.00 166,464 166,464 1138 Nurse Practitioner 1.00 166,464 166,464 1139 Nurse Practitioner 1.00 166,464 166,464 1140 Nurse Practitioner 1.00 166,464 166,464 1141 Nurse Practitioner 1.00 166,464 166,464 1142 Nurse Practitioner 1.00 166,464 166,464 1143 Nurse Practitioner 1.00 166,464 166,464 Direct Personnel Program Salaries Subtotal 25.70 7,019,867.00 7,019,867.00 Admin Program Total Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Revised Exhibit B-1 Page 10 of 16 Direct Personnel Salaries Subtotall 27.60 1 $ 1,753,235 1 $ 7,019,867 1 $ 8,773,102 Direct Employee Benefits Acct# Description Admin Program Total 1201 Retirement $ 5,443 $ 188,438 $ 193,881 1202 Worker's Compensation 740 48,160 48,900 1203 Health Insurance 11,753 397,507 409,260 1204 Other(specify)-Malpractice 478 91,040 91,518 1205 10ther(specify) - - - 1206 10ther(specify) - - - Direct Employee Benefits Subtotal: $ 18,414 $ 725,145 $ 743,559 Direct Payroll Taxes&Expenses: Acct# Description Admin Program Total 1301 OASDI $ 4,929 $ 238,162 $ 243,091 1302 FICA/MEDICARE 1,651 107,433 109,084 1303 SUI 262 6,402 6,664 1304 Other(specify) - - - 1305 10ther(specify) - - 1306 10ther(specify) - - - Direct Payroll Taxes&Expenses Subtotal: $ 6,842 $ 351,997 $ 358,839 DIRECT EMPLOYEE SALARIES&BENEFITS TOTAL: Admin Program Total $ 1,778,491 $ 8,097,009 $ 9,875,500 DIRECT EMPLOYEE SALARIES&BENEFITS PERCENTAGE: Admin Program 18% 82% 2000: DIRECT CLIENT SUPPORT Acct# Line Item Description Amount 2001 Child Care $ - 2002 Client Housing Support - 2003 Client Transportation&Support - 2004 Clothing, Food,&Hygiene - 2005 Education Support - 2006 Employment Support - 2007 Household Items for Clients - 2008 Medication Supports - 2009 Program Supplies-Medical - 2010 Utility Vouchers - 2011 Other(specify) - 2012 Other(specify) - 2013 Other(specify) - 2014 Other(specify) - 2015 10ther(specify) - 2016 10ther(specify) - DIRECT CLIENT CARE TOTAL $ - 3000:DIRECT OPERATING EXPENSES Acct# Line Item Description Amount 3001 Telephone $ 33,600 3002 Printing/Postage - 3003 Office,Household&Program Supplies - 3004 Advertising - 3005 Staff Development&Training - 3006 Staff Mileage - 3007 Subscriptions&Memberships - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Revised Exhibit B-1 Page 11 of 16 3008 Vehicle Maintenance - 3009 Other(Food) 21,480 3010 Other(Lodging) 36,400 3011 Other(Recruiting) 562,830 3012 Other(Airfare) 24,400 3013 Other(Rental Car) 10,200 DIRECT OPERATING EXPENSES TOTAL:1 $ 688,910 4000: DIRECT FACILITIES&EQUIPMENT Acct# Line Item Description Amount 4001 Building Maintenance $ - 4002 Rent/Lease Building - 4003 Rent/Lease Equipment - 4004 Rent/Lease Vehicles - 4005 Security - 4006 Utilities - 4007 Other(specify) - 4008 Other(specify) - 4009 Other(specify) - 4010 10ther(specify) - DIRECTFACILITIES/EQUIPMENTTOTAL: $ - 5000:DIRECT SPECIAL EXPENSES Acct# Line Item Description Amount 5001 Consultant(Network&Data Management) $ 1,800 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) - 5004 Translation Services - 5005 Other(specify) - 5006 Other(specify) - 5007 Other(specify) - 5008 Other(specify) - DIRECT SPECIAL EXPENSES TOTAL:1 $ 1,800 6000: INDIRECT EXPENSES Acct# Line Item Description Amount Administrative Overhead 6001 Use this line and only this line for approved indirect cost rate $ - Administrative Overhead 6002 Professional Liability Insurance - 6003 Accounting/Bookkeeping - 6004 External Audit - 6005 Insurance(Specify): - 6006 Payroll Services - 6007 Depreciation(Provider-Owned Equipment to be Used for Program Purposes) - 6008 Personnel(Indirect Salaries&Benefits) - 6009 Other(Administrative Overhead) $ 1,584,932 6010 Other(specify) - 6011 Other(specify) - 6012 Other(specify) - 6013 10ther(specify) - INDIRECT EXPENSES TOTAL $ 1,584,932 INDIRECT COST RATE 15.00% Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Revised Exhibit B-1 Page 12 of 16 7000:DIRECT FIXED ASSETS Acct# Line Item Description Amount 7001 Computer Equipment&Software $ - 7002 Copiers,Cell Phones,Tablets, Devices to Contain HIPAA Data - 7003 Furniture&Fixtures - 7004 Leasehold/Tenant/Building Improvements - 7005 Other Assets over$500 with Lifespan of 2 Years+ - 7006 Assets over$5,000/unit(Specify) - 7007 Other(specify) - 7008 Other(specify) - FIXED ASSETS EXPENSES TOTAL $ - TOTAL PROGRAM EXPENSES $ 12,151,142 PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) Acct# Line Item Description Service Units Rate Amount 8001 Mental Health Services 0 - $ - 8002 Case Management 0 - 8003 Crisis Services 0 - - 8004 Medication Support 0 - 8005 Collateral 0 - - 8006 Plan Development 0 - 8007 Assessment 0 - - 8008 Rehabilitation 0 - 8009 Other(Specify) 0 - 8010 10ther(Specify) 0 - Estimated Specialty Mental Health Services Billing Totals: 0 $ - Estimated%of Clients who are Medi-Cal Beneficiaries 77 Estimated Total Cost of Specialty Mental Health Services Provided to Medi-Cal Beneficiaries - Federal Financial Participation(FFP)% 1 0% MEDI-CAL FFP TOTAL $ - 8100-SUBSTANCE USE DISORDER FUNDS Acct# Line Item Description Amount 8101 Drug Medi-Cal $ - 8102 SABG $ - SUBSTANCE USE DISORDER FUNDS TOTAL $ - 8200-REALIGNMENT Acct# Line Item Description Amount 8201 lRealignment $ 12,151,142 REALIGNMENT TOTAL $ 12,151,142 8300-MENTAL HEALTH SERVICE ACT(MHSA) Acct# MHSA Component MHSA Program Name Amount 8301 CSS-Community Services&Supports $ - 8302 PEI-Prevention&Early Intervention - 8303 INN-Innovations - 8304 WET-Workforce Education&Training - 8305 JCFTN-Capital Facilities&Technology - MHSA TOTAL $ - 8400-OTHER REVENUE Acct# Line Item Description Amount Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Revised Exhibit B-1 Page 13 of 16 8401 Client Fees $ - 8402 Client Insurance - 8403 Grants(Specify) - 8404 Other(Specify) - 8405 Other(Specify) - OTHER REVENUE TOTAL $ - TOTAL PROGRAM FUNDING SOURCES: $ 12,151,142 NET PROGRAM COST: $ - Fresno County Department of Behavioral Health Contract Budget Template Revised 4/10/2020 Revised Exhibit B-1 Page 14 of 16 CCFMG Fiscal Year(FY)2024-25 Budget Narrative PROGRAM EXPENSE ACCT#I LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1000:DIRECT SALARIES&BENEFITS 9,875,500 Administrative Positions 1,753,235 1101 Medical Director-Dr.Tran 438,007 2%increase each July 1;Administrative responsibilities for Medical Director 1102 Executive Assistant-Shelley McNiff 65,228 2%increase each July 1;administrative support for Medical Director 1103 Retention Bonus 390,000 $30k per 8 vacant MDs and$15k per 10 vacant NPs.Paid in return for 3 years service 1104 Relocation Cost 360,000 $20k per 18 potentially vacant MD/NP positions base upon IRS guidelines;must show receipts 1105 Loan Repayment Cost 500,000 $50k per vacant MD(8) 1106 0 - 1107 0 1108 0 1109 0 1110 0 1111 0 1112 0 1113 0 1114 0 1115 0 Program Positions 7,019,867 1116 Medical Director-Dr.Tran 48,668 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1117 Interim Assistant Chief Peds-Dr.Cheema 233,466 2%increase from previous year;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties;some oversight of psychiatrists and nurse practitioners 1118 Psychiatrist-Dr.Benavidez 371,423 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1119 Psychiatrist-Dr.Domaska 371,423 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1120 Psychiatrist-Dr.Chavira 371,423 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1121 Psychiatrist-Dr.Hang 364,140 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1122 Psychiatrist-Dr.Robles 364,140 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1123 Psychiatrist 335,009 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties;split duties with Psychiatrist Chart Review(line 1124) 1124 Psychiatrist Chart Review 29,131 (Vacant)Medication monitoring;split duties for Psychiatrist(line 1123) 1125 Psychiatrist 364,140 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1126 Psychiatrist 364,140 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1127 Psychiatrist 364,140 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1128 Psychiatrist 364,140 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1129 Psychiatrist 364,140 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1130 Psychiatrist 364,140 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1131 Psychiatrist 364,140 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1132 PharmacistD 150,960 (Vacant)2%increase each July 1;clinical pharmacist,assess appropriateness/effectiveness/safety of all medications for patients enrolled in service, assist in disease state management 1133 Nurse Practitioner-Hope Lo 166,464 2%increase each July 1;psychiatry assessments/evaluations,medication management, and other psychiatry-related duties 1134 Nurse Practitioner 166,464 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1135 Nurse Practitioner 166,464 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1136 Nurse Practitioner 166,464 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1137 Nurse Practitioner 166,464 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1138 Nurse Practitioner 166,464 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1139 Nurse Practitioner 166,464 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties Fresno County Department of Behavioral Health Contract Budget Narrative Revised 217/2020 Revised Exhibit B-1 Page 15 of 16 PROGRAM EXPENSE ACCT#j LINE ITEM AMT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 1140 Nurse Practitioner 166,464 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1141 Nurse Practitioner 166,464 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1142 Nurse Practitioner 166,464 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties 1143 Nurse Practitioner 166,464 (Vacant)2%increase each July 1;psychiatry assessments/evaluations,medication management,and other psychiatry-related duties Direct Employee Benefits 743,559 1201 Retirement 193,881 1202 Worker's Compensation 48,900 1203 Health Insurance 409,260 1204 Other(specify)-Malpractice 91,518 1205 Other(specify) - 1206 Other(specify) - Direct Payroll Taxes&Expenses: 358,839 1301 OASDI 243,091 1302 FICA/MEDICARE 109,084 1303 SUI 6,664 1304 Other(specify) - 1305 Other(specify) 1306 Other(specify) 2000:DIRECT CLIENT SUPPORT 2001 Child Care 2002 Client Housing Support 2003 Client Transportation&Support 2004 Clothing,Food,&Hygiene 2005 Education Support 2006 Employment Support 2007 Household Items for Clients 2008 Medication Supports 2009 Program Supplies-Medical 2010 Utility Vouchers 2011 Other(specify) 2012 Other(specify) 2013 Other(specify) 2014 Other(specify) 2015 Other(specify) 2016 1 Other(specify) 3000:DIRECT OPERATING EXPENSES 688,910 3001 Telephone 33,600 Phone charges @$100/month per FTE 3002 Printing/Postage - 3003 Office,Household&Program Supplies 3004 Advertising 3005 Staff Development&Training 3006 Staff Mileage 3007 Subscriptions&Memberships - 3008 Vehicle Maintenance 3009 Other(Food) 21,480 per candidate estimate when coming onsite for interview+staff meals and candidate group meals at conference 3010 Other(Lodging) 36,400 per candidate estimate when coming onsite for interview+standard rate x number of conferences planned 3011 Other(Recruiting) 562,830 Recruiting charges from staffing agency($35K/MD and$22K/NP)+estimated conference fees and advertising costs 3012 Other(Airfare) 24,400 per candidate estimate when coming onsite for interview+$1200/person(flights+ baggage fees)x 8 planned conferences(added additional$400 for misc fees) 3013 1 Other(Rental Car) 10,200 1 per candidate estimate when coming onsite for interview 4000:DIRECT FACILITIES&EQUIPMENT - 4001 Building Maintenance 4002 Rent/Lease Building 4003 Rent/Lease Equipment 4004 Rent/Lease Vehicles 4005 Security 4006 Utilities 4007 Other(specify) 4008 Other(specify) 4009 Other(specify) 4010 1 Other(specify) Fresno County Department of Behavioral Health Contract Budget Narrative Revised 217/2020 Revised Exhibit B-1 Page 16 of 16 PROGRAM EXPENSE ACCT#I LINE ITEM ANT DETAILED DESCRIPTION OF ITEMS BUDGETED IN EACH ACCOUNT LINE 5000:DIRECT SPECIAL EXPENSES 1,800 5001 Consultant(Network&Data Management) 1,800 3rd party IT services for network and data 5002 HMIS(Health Management Information System) - 5003 Contractual/Consulting Services (Specify) 5004 Translation Services 5005 Other(specify) 5006 Other(specify) 5007 Other(specify) 5008 1 Other(specify) 6000:INDIRECT EXPENSES 1,584,932 6001 Administrative Overhead - 6002 Professional Liability Insurance 6003 Accounting/Bookkeeping 6004 External Audit 6005 Insurance(Specify): 6006 Payroll Services 6007 Depreciation(Provider-Owned Equipment to be Used 6008 Personnel(Indirect Salaries&Benefits) - 6009 Other(Administrative Overhead) 1,584,932 Expenses fund corporate expenses related to administration of provider employment, contract administration,financial review,and ongoing contract management. Administrative Overhead costs are 15%of total expenses. 6010 Other(specify) 6011 Other(specify) 6012 Other(specify) 6013 1 Other(specify) 7000:DIRECT FIXED ASSETS 7001 Computer Equipment&Software 7002 Copiers,Cell Phones,Tablets,Devices to Contain HIPAA 7003 Furniture&Fixtures 7004 Leasehold/Tenant/Building Improvements 7005 Other Assets over$500 with Lifespan of 2 Years+ 7006 Assets over$5,000/unit(Specify) 7007 Other(specify) 7008 1 Other(specify) PROGRAM FUNDING SOURCES 8000-SHORT/DOYLE MEDI-CAL(FEDERAL FINANCIAL PARTICIPATION) PROVIDE DETAILS OF METHODOLOGY(IES)USED IN DETERMINING MEDI-CAL ACCT# LINE ITEM SERVICE RATES AND/OR SERVICE UNITS,IF APPLICABLE AND/OR AS REQUIRED BY THE RFP 8001 Mental Health Services 8002 Case Management 8003 Crisis Services 8004 Medication Support 8005 Collateral 8006 Plan Development 8007 Assessment 8008 Rehabilitation 8009 Other(Specify) 8010 Other(Specify) TOTAL PROGRAM EXPENSE FROM BUDGET NARRATIVE: 12,151,142 TOTAL PROGRAM EXPENSES FROM BUDGET TEMPLATE: 12,151,142 BUDGETCHECK: - Fresno County Department of Behavioral Health Contract Budget Narrative Revised 217/2020 Revised Exhibit D Page 1 of 3 DOCUMENTATION STANDARDS FOR CLIENT RECORDS The documentation standards are described below under key topics related to client care. All standards must be addressed in the client record; however, there is no requirement that the record have a specific document or section addressing these topics. All medical records shall be maintained for a minimum of 10 years from the date of the end of the Agreement. A. Assessments 1. The following areas will be included as a part of a comprehensive client record: • Presenting problems, including impairments in function, and current mental status exam. • Traumatic incidents which include trauma exposures, trauma reactions, trauma screenings, and systems involvement if relevant • Behavioral health history including mental health history, substance use/abuse, and previous services • Medical history including physical health conditions, medications, and developmental history • Psychosocial factors including family, social and life circumstances, cultural considerations • Strengths, risks, and protective factors, including safety planning • Clinical summary, treatment recommendations, and level of care determination including diagnostic and clinical impression with a diagnosis • The assessment shall include a typed or legibly printed name, signature of the service provider and date of signature. 2. Timeliness/Frequency Standard for Assessment • The time period to complete an initial assessment and subsequent assessments for SMHS is up to clinical discretion. • Assessments shall be completed within a reasonable time and in accordance with generally accepted standards of practice. B. Problem list The use of a Problem List has largely replaced the use of treatment plans and is therefore required to be part of the client record. The problem list shall be updated on an ongoing basis to reflect the current presentation of the person in care. The problem list shall include, but is not limited to, the following: • Diagnoses identified by a provider acting within their scope of practice • Problems identified by a provider acting within their scope of practice • Problems or illnesses identified by the person in care and/or significant support person if any • The name and title of the provider that identified, added, or removed the problem, and the date the problem was identified, added, or removed C. Treatment and Care Plan Requirements 1. Targeted Case Management Revised Exhibit D Page 2 of 3 • Specifies the goals, treatment, service activities, and assistance to address the negotiated objectives of the plan and the medical, social, educational, and other services needed by the person in care • Identifies a course of action to respond to the assessed needs of the person in care • Includes development of a transition plan when the person in care has achieved the goals of the care plan • Peer support services must be based on an approved care plan • Must be provided in a narrative format in the person's progress notes • Updated at least annually 2. Services requiring Treatments Plans • Intensive Home-Based Services (IHBS) • Intensive Care Coordination (ICC) • Therapeutic Behavioral Services (TBS) • Must have specific observable and/or specific quantifiable goals • Must identify the proposed type(s) of intervention • Must be signed (or electronic equivalent) by: ➢ the person providing the service(s), or ➢ a person representing a team or program providing services, or ➢ a person representing the MHP providing services ➢ when the client plan is used to establish that the services are provided under the direction of an approved category of staff, and if the below staff are not the approved category, ➢ a physician ➢ a licensed/ "waivered" psychologist ➢ a licensed/ "associate" social worker ➢ a licensed/ registered/marriage and family therapist or ➢ a registered nurse • In addition, ➢ Client plans will be consistent with the diagnosis, and the focus of intervention will be consistent with the client plan goals, and there will be documentation of the client's participation in and agreement with the plan. Examples of the documentation include, but are not limited to, reference to the client's participation and agreement in the body of the plan, client signature on the plan, or a description of the client's participation and agreement in progress notes. ➢ Client signature on the plan will be used as the means by which the CONTRACTOR documents the participation of the client. When the client's signature is required on the client plan and the client refuses or is unavailable for signature, the client plan will include a written explanation of the refusal or unavailability. ➢ The CONTRACTOR will give a copy of the client plan to the client on request. D. Progress Notes Revised Exhibit D Page 3 of 3 1. Providers shall create progress notes for the provision of all SMHS. Each progress note shall provide sufficient detail to support the service code selected for the service type as indicated by the service code description. Progress notes shall include: • The type of service rendered. • A narrative describing the service, including how the service addressed the beneficiary's behavioral health need (e.g., symptom, condition, diagnosis, and/or risk factors). • The date that the service was provided to the beneficiary. • Duration of the service, including travel and documentation time. • Location of the beneficiary at the time of receiving the service. • A typed or legibly printed name, signature of the service provider and date of signature. • ICD 10 code • Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code. • Next steps including, but not limited to, planned action steps by the provider or by the beneficiary, collaboration with the beneficiary, collaboration with other provider(s) and any update to the problem list as appropriate. 2. Timeliness/Frequency of Progress Notes • Progress notes shall be completed within 3 business days of providing a service, except for notes for crisis services, which shall be completed within 24 hours. • A note must be completed for every service contact Revised Exhibit E BEHAVIORAL HEALTH REQUIREMENTS 1. CONTROL REQUIREMENTS The County and its subcontractors shall provide services in accordance with all applicable Federal and State statutes and regulations. 2. PROFESSIONAL LICENSURE All (professional level) persons employed by the County Mental Health Plan (directly or through contract) providing Short-Doyle/Medi-Cal services have met applicable professional licensure requirements pursuant to Business and Professions and Welfare and Institutions Codes. 3. CONFIDENTIALITY Contractor shall conform to and County shall monitor compliance with all State of California and Federal statutes and regulations regarding confidentiality, including but not limited to confidentiality of information requirements at 42, Code of Federal Regulations sections 2.1 et seq; California Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division 10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the California Civil Code. 4. NON-DISCRIMINATION A. Eligibility for Services Contractor shall prepare and make available to County and to the public all eligibility requirements to participate in the program plan set forth in the Agreement. No person shall, because of ethnic group identification, age, gender, color, disability, medical condition, national origin, race, ancestry, marital status, religion, religious creed, political belief or sexual preference be excluded from participation, be denied benefits of, or be subject to discrimination under any program or activity receiving Federal or State of California assistance. B. Employment Opportunity Contractor shall comply with County policy, and the Equal Employment Opportunity Commission guidelines, which forbids discrimination against any person on the grounds of race, color, national origin, sex, religion, age, disability status, or sexual preference in employment practices. Such practices include retirement, recruitment advertising, hiring, layoff, termination, upgrading, demotion, transfer, rates of pay or other forms of compensation, use of facilities, and other terms and conditions of employment. E-1 Revised Exhibit E C. Suspension of Compensation If an allegation of discrimination occurs, County may withhold all further funds, until Contractor can show clear and convincing evidence to the satisfaction of County that funds provided under this Agreement were not used in connection with the alleged discrimination. D. Nepotism Except by consent of County's Department of Behavioral Health Director, or designee, no person shall be employed by Contractor who is related by blood or marriage to, or who is a member of the Board of Directors or an officer of Contractor. 5. PATIENTS' RIGHTS Contractor shall comply with applicable laws and regulations, including but not limited to, laws, regulations, and State policies relating to patients' rights. STATE CONTRACTOR CERTIFICATION CLAUSES 1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied with the non-discrimination program requirements. (Gov. Code§ 12990 (a-f) and CCR, Title 2, Section 111 02) (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 this 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 this Agreement. E-2 Revised Exhibit E Failure to comply with these requirements may result in suspension of payments under this Agreement or termination of this 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 (2) 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. Contractor further declares under penalty of perjury that they adhere to the Sweatfree Code of Conduct as set forth on E-3 Revised Exhibit E the California Department of Industrial Relations website located at www.dir.ca.gov, and Public Contract Code Section 6108. b. 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 this Agreement, the awarding agency must be contacted immediately for clarification. Current State Employees (Pub. Contract Code M 0410): a). 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. b). 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): a). For the two (2) 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. E-4 Revised Exhibit E b). For the twelve (12) 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 twelve (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. E-5 Revised Exhibit E 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. 9. INSPECTION AND AUDIT OF RECORDS AND ACCESS TO FACILITIES: The State, CMS, the Office of the Inspector General, the Comptroller General, and their designees may, at any time, inspect and audit any records or documents of Contractor or its subcontractors, and may, at any time, inspect the premises, physical facilities, and equipment where Medicaid-related activities or work is conducted. The right to audit under this section exists for ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later. Federal database checks. Consistent with the requirements at § 455.436 of this chapter, the State must confirm the identity and determine the exclusion status of Contractor, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of Contractor through routine checks of Federal databases. This includes the Social Security Administration's Death Master File, the National Plan and Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE), the System for Award Management (SAM), and any other databases as the State or Secretary may prescribe. These databases must be consulted upon contracting and no less frequently than monthly thereafter. If the State finds a party that is excluded, it must promptly notify the Contractor and take action consistent with § 438.610(c). The State must ensure that Contractor with which the State contracts under this part is not located outside of the United States and that no claims paid by a Contractor to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. E-6 Revised Exhibit E CALIFORNIA ADVANCING AND INNOVATING MEDI-CAL (CAL-AIM) REQUIREMENTS 1. SERVICES AND ACCESS PROVISIONS a. CERTIFICATION OF ELIGIBILITY i. Contractor will, in cooperation with County, comply with Section 14705.5 of California Welfare and Institutions Code to obtain a certification of an individual's eligibility for Specialty Mental Health Services (SMHS) under Medi-Cal. b. ACCESS TO SPECIALTY MENTAL HEALTH SERVICES i. In collaboration with the County, Contractor will work to ensure that individuals to whom the Contractor provides SMHS meet access criteria, as per Department of Health Care Services (DHCS) guidance specified in BHIN 21-073. Specifically, the Contractor will ensure that the clinical record for each individual includes information as a whole indicating that individual's presentation and needs are aligned with the criteria applicable to their age at the time of service provision as specified below. ii. For enrolled individuals under 21 years of age, Contractor shall provide all medically necessary SMHS required pursuant to Section 1396d(r) of Title 42 of the United States Code. Covered SMHS shall be provided to enrolled individuals who meet either of the following criteria, (1) or (11) below. If an individual under age 21 meets the criteria as described in (1) below, the beneficiary meets criteria to access SMHS; it is not necessary to establish that the beneficiary also meets the criteria in (b) below. 1. The individual 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 approved by DHCS, involvement in the child welfare system, juvenile justice involvement, or experiencing homelessness. OR 2. The individual has at least one of the following: a. A significant impairment b. A reasonable probability of significant deterioration in an important area of life functioning c. A reasonable probability of not progressing developmentally as appropriate. d. A need for SMHS, regardless of presence of impairment, that are not included within the mental health benefits that a Medi-Cal Managed Care Plan (MCP) is required to provide. AND the individual's condition as described in subparagraph (11 a-d) above is due to one of the following: E-7 Revised Exhibit E a. A diagnosed mental health disorder, according to the criteria in the current editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases and Related Health Problems (ICD). b. A suspected mental health disorder that has not yet been diagnosed. c. Significant trauma placing the individual at risk of a future mental health condition, based on the assessment of a licensed mental health professional. iii. For individuals 21 years of age or older, Contractor shall provide covered SMHS for clients who meet both of the following criteria, (a) and (b) below: 1. The individual 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. 2. The individual's condition as described in paragraph (a) is due to either of the following: a. A diagnosed mental health disorder, according to the criteria in the current editions of the DSM and ICD. b. A suspected mental disorder that has not yet been diagnosed. c. ADDITIONAL CLARIFICATIONS i. Criteria 1. A clinically appropriate and covered mental health prevention, screening, assessment, treatment, or recovery service listed within Exhibit A of this Agreement can be provided and submitted to the County for reimbursement under any of the following circumstances: a. The services were provided prior to determining a diagnosis, including clinically appropriate and covered services provided during the assessment process; b. The service was not included in an individual treatment plan; or c. The individual had a co-occurring substance use disorder. ii. Diagnosis Not a Prerequisite 1. Per BHIN 21-073, a mental health diagnosis is not a prerequisite for access to covered SMHS. This does not eliminate the requirement that all Medi-Cal claims, including SMHS claims, include a current Centers for E-8 Revised Exhibit E Medicare & Medicaid Services (CMS) approved ICD diagnosis code d. MEDICAL NECESSITY i. Contractor will ensure that services provided are medically necessary in compliance with BHIN 21-073 and pursuant to Welfare and Institutions Code section 14184.402(a). Services provided to a client must be medically necessary and clinically appropriate to address the individual's presenting condition. Documentation in each individual's chart as a whole will demonstrate medical necessity as defined below, based on the client's age at the time of service provision. ii. 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. iii. 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. e. COORDINATION OF CARE i. Contractor shall ensure that all care, treatment and services provided pursuant to this Agreement are coordinated among all providers who are serving the individual, including all other SMHS providers, as well as providers of Non-Specialty Mental Health Services (NSMHS), substance use disorder treatment services, physical health services, dental services, regional center services and all other services as applicable to ensure a client-centered and whole-person approach to services. ii. Contractor shall ensure that care coordination activities support the monitoring and treatment of comorbid substance use disorder and/or health conditions. iii. Contractor shall include in care coordination activities efforts to connect, refer and link individual s to community-based services and supports, including but not limited to educational, social, prevocational, vocational, housing, nutritional, criminal justice, transportation, childcare, child development, family/marriage education, cultural sources, and mutual aid support groups. iv. Contractor shall engage in care coordination activities beginning at intake and throughout the treatment and discharge planning processes. v. To facilitate care coordination, Contractor will request a HIPAA and California law compliant client authorization to share the individual's information with and among all other providers involved in the individual's care, in satisfaction of state and federal privacy laws and regulations. f. CO-OCCURRING TREATMENT AND NO WRONG DOOR E-9 Revised Exhibit E i. Per BHIN 22-011, Specialty and Non-Specialty Mental Health Services can be provided concurrently, if those services are clinically appropriate, coordinated, and not duplicative. When a client meets criteria for both NSMHS and SMHS, the individual should receive services based on individual clinical need and established therapeutic relationships. Clinically appropriate and covered SMHS can also be provided when the individual has a co- occurring mental health condition and substance use disorder. ii. Under this Agreement, Contractor will ensure that individual s receive timely mental health services without delay. Services are reimbursable to Contractor by County even when: 1. Services are provided prior to determination of a diagnosis, during the assessment or prior to determination of whether SMHS access criteria are met, even if the assessment ultimately indicates the individual does not meet criteria for SMHS. 2. If Contractor is serving an individual receiving both SMHS and NSMHS, Contractor holds responsibility for documenting coordination of care and ensuring that services are non-duplicative. 2. AUTHORIZATION AND DOCUMENTATION PROVISIONS a. SERVICE AUTHORIZATION i. Contractor will collaborate with County to complete authorization requests in line with County and DHCS policy. ii. Contractor shall have in place, and follow, written policies and procedures for completing requests for initial and continuing authorizations of services, as required by County guidance. iii. Contractor shall respond to County in a timely manner when consultation is necessary for County to make appropriate authorization determinations. iv. County shall provide Contractor with written notice of authorization determinations within the timeframes set forth in BHINs 22-016 and 22-017, or any subsequent DHCS notices. v. Contractor shall alert County when an expedited authorization decision (no later than 72 hours) is necessary due to an individual's specific needs and circumstances that could seriously jeopardize the individual s life or health, or ability to attain, maintain, or regain maximum function. b. DOCUMENTATION REQUIREMENTS i. Contractor will follow all documentation requirements as specified in Article 4.2-4.8 inclusive in compliance with federal, state and County requirements. ii. All Contractor documentation shall be accurate, complete, and legible, shall list each date of service, and include the face-to-face time for each service. Contractor shall document travel and documentation time for each service separately from face-to-face time and provide this information to County upon request. E-10 Revised Exhibit E Services must be identified as provided in-person, by telephone, or by telehealth. iii. All services shall be documented utilizing County-approved templates and contain all required elements. Contractor agrees to satisfy the chart documentation requirements set forth in BHIN 22- 019 and the contract between County and DHCS. Failure to comply with documentation standards specified in this Article require corrective action plans. c. ASSESSMENT i. Contractor shall ensure that all individuals' medical records include an assessment of each individual's need for mental health services. ii. Contractor will utilize the seven uniform assessment domains and include other required elements as identified in BHIN 22-019 and document the assessment in the individual's medical record. iii. For individuals aged 6 through 21, the Child and Adolescent Needs and Strengths (CANS), and for individual s aged 3 through 18, the Pediatric Symptom Checklist-35 (PSC-35) tools are required at intake, every six months during treatment, and at discharge, as specified in DHCS MHSUDS INs 17-052 and 18- 048. iv. The time period for providers to complete an initial assessment and subsequent assessments for SMHS are up to clinical discretion of County; however, Contractor's providers shall complete assessments within a reasonable time and in accordance with generally accepted standards of practice. d. ICD-10 i. Contractor shall use the criteria set forth in the current edition of the DSM as the clinical tool to make diagnostic determinations. ii. Once a DSM diagnosis is determined, the Contractor shall determine the corresponding mental health diagnosis in the current edition of ICD. Contractor shall use the ICD diagnosis code(s) to submit a claim for SMHS to receive reimbursement from County. iii. The ICD Tabular List of Diseases and Injuries is maintained by CMS and may be updated during the term of this Agreement. Changes to the lists of ICD diagnoses do not require an amendment to this Agreement, and County may implement these changes as provided by CMS e. PROBLEM LIST i. Contractor will create and maintain a Problem List for each individual served under this Agreement. The problem list is a list of symptoms, conditions, diagnoses, and/or risk factors identified through assessment, psychiatric diagnostic evaluation, crisis encounters, or other types of service encounters. ii. Contractor must document a problem list that adheres to industry standards utilizing at minimum current SNOMED International, E-11 Revised Exhibit E Systematized Nomenclature of Medicine Clinical Terms (SNOMED CTO) U.S. Edition, September 2022 Release, and ICD- 10-CM 2023. iii. A problem identified during a service encounter may be addressed by the service provider during that service encounter and subsequently added to the problem list. iv. The problem list shall include, but is not limited to, all elements specified in BHIN 22-019. v. County does not require the problem list to be updated within a specific timeframe or have a requirement about how frequently the problem list should be updated after a problem has initially been added. However, Contractor shall update the problem list within a reasonable time such that the problem list reflects the current issues facing the client, in accordance with generally accepted standards of practice and in specific circumstances specified in BHIN 22-019. f. TREATMENT AND CARE PLANS i. Contractor is not required to complete treatment or care plans for clients under this Agreement, except in the circumstances specified in BHIN 22-019 and additional guidance from DHCS that may follow after execution of this Agreement. g. PROGRESS NOTES i. Contractor shall create progress notes for the provision of all SMHS services provided under this Agreement. ii. Each progress note shall provide sufficient detail to support the service code selected for the service type as indicated by the service code description. iii. Progress notes shall include all elements specified in BHIN 22- 019, whether the note be for an individual or a group service. iv. Contractor shall complete progress notes within three business days of providing a service, with the exception of notes for crisis services, which shall be completed within 24 hours. v. Providers shall complete a daily progress note for services that are billed on a daily basis, such as residential and day treatment services, if applicable. h. TRANSITION OF CARE TOOL i. Contractor shall use a Transition of Care Tool for any individual whose existing services will be transferred from Contractor to an Medi-Cal Managed Care Plan (MCP) provider or when NSMHS will be added to the existing mental health treatment provided by Contractor, as specified in BHIN 22-065, in order to ensure continuity of care. ii. Determinations to transition care or add services from an MCP shall be made in alignment with County policies and via a person- centered, shared decision-making process. iii. Contractor may directly use the DHCS-provided Transition of Care Tool, found at https://www.dhcs.ca.gov/Pages/Screening-and- E-12 Revised Exhibit E Transition-of-Care-Tools-for-Medi-Cal-Mental-Health- Services.aspx, or obtain a copy of that tool provided by the County. Contractor may create the Transition of Care Tool in its Electronic Health Record (EHR). However, the contents of the Transition of Care Tool, including the specific wording and order of fields, shall remain identical to the DHCS provided form. The only exception to this requirement is when the tool is translated into languages other than English. i. TELEHEALTH i. Contractor may use telehealth, when it deems clinically appropriate, as a mode of delivering behavioral health services in accordance with all applicable County, state, and federal requirements, including those related to privacy/security, efficiency, and standards of care. Such services will conform to the definitions and meet the requirements included in the Medi-Cal Provider Manual: Telehealth, available in the DHCS Telehealth Resources page at: https://www.dhcs.ca.gov/provqovpart/Pages/TelehealthResources .aspx. ii. All telehealth equipment and service locations must ensure that client confidentiality is maintained. iii. Licensed providers and staff may provide services via telephone and telehealth as long as the service is within their scope of practice. iv. Medical records for individuals served by Contractor under this Agreement must include documentation of written or verbal consent for telehealth or telephone services if such services are provided by Contractor. Such consent must be obtained at least once prior to initiating applicable health care services and consent must include all elements as specified in BHIN 22-019. v. County may at any time audit Contractor's telehealth practices, and Contractor must allow access to all materials needed to adequately monitor Contractor's adherence to telehealth standards and requirements. 3. CLIENT PROTECTIONS a. GRIEVANCES, APPEALS AND NOTICES OF ADVERSE BENEFIT DETERMINATION i. All grievances (as defined by 42 C.F.R. § 438.400) and complaints received by Contractor must be immediately forwarded to the County's Managed Care Department or other designated persons via a secure method (e.g., encrypted email or by fax) to allow ample time for the Managed Care staff to acknowledge receipt of the grievance and complaints and issue appropriate responses. ii. Contractor shall not discourage the filing of grievances and individual s do not need to use the term "grievance" for a complaint to be captured as an expression of dissatisfaction and, therefore, a grievance. E-13 Revised Exhibit E iii. Aligned with MHSUDS IN 18-010E and 42 C.F.R. §438.404, the appropriate and delegated Notice of Adverse Benefit Determination (NOABD) must be issued by Contractor within the specified timeframes using the template provided by the County. iv. NOABDs must be issued to individuals anytime the Contractor has made or intends to make an adverse benefit determination that includes the reduction, suspension, or termination of a previously authorized service and/or the failure to provide services in a timely manner. The notice must have a clear and concise explanation of the reason(s) for the decision as established by DHCS and the County. The Contractor must inform the County immediately after issuing a NOABD. v. Procedures and timeframes for responding to grievances, issuing and responding to adverse benefit determinations, appeals, and state hearings must be followed as per 42 C.F.R., Part 438, Subpart F (42 C.F.R. §§ 438.400 —438.424). vi. Contractor must provide individuals any reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal such as auxiliary aids and interpreter services. vii. Contractor must maintain records of grievances and appeals and must review the information as part of its ongoing monitoring procedures. The record must be accurately maintained in a manner accessible to the County and available upon request to DHCS. b. Advanced Directives i. Contractor must comply with all County policies and procedures regarding Advanced Directives in compliance with the requirements of 42 C.F.R. §§ 422.128 and 438.6(i) (1), (3) and (4). c. Continuity of Care i. Contractor shall follow the County's continuity of care policy that is in accordance with applicable state and federal regulations, MHSUDS IN 18-059 and any BHINs issued by DHCS for parity in mental health and substance use disorder benefits subsequent to the effective date of this Agreement (42 C.F.R. § 438.62(b)(1)-(2).) 4. QUALITY IMPROVEMENT PROGRAM a. QUALITY IMPROVEMENT ACTIVITIES AND PARTICIPATION i. Contractor shall implement mechanisms to assess person served/family satisfaction based on County's guidance. The Contractor shall assess individual/family satisfaction by: 1. Surveying person served/family satisfaction with the Contractor's services at least annually. 2. Evaluating person served's grievances, appeals and State Hearings at least annually. 3. Evaluating requests to change persons providing services at least annually. E-14 Revised Exhibit E 4. Informing the County and individuals of the results of client/family satisfaction activities. ii. Contractor, if applicable, shall implement mechanisms to monitor the safety and effectiveness of medication practices. This mechanism shall be under the supervision of a person licensed to prescribe or dispense prescription drugs, at least annually and as required by DBH. iii. 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 and shared with the County. iv. Contractor shall assist County, as needed, with the development and implementation of Corrective Action Plans. v. Contractor shall collaborate with County to create a County's QI Work Plan with documented annual evaluations and documented revisions as needed. The Ql Work Plan shall evaluate the impact and effectiveness of its quality assessment and performance improvement program. vi. Contractor shall attend and participate in the County's Quality Improvement Committee (QIC) to recommend policy decisions, review and evaluate results of QI activities, including PIPs, institute needed Ql actions, and ensure follow-up of Ql processes. Contractor shall ensure that there is active participation by the Contractor's practitioners and providers in the QIC. vii. Contractor shall participate, as required, in annual, independent external quality reviews (EQR) 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) b. TIMELY ACCESS i. Timely access standards include: 1. Contractor must have hours of operation during which services are provided to Medi-Cal individuals that are no less than the hours of operation during which the provider offers services to non-Medi-Cal individual s. If the Contractor's provider only serves Medi-Cal clients, the provider must provide hours of operation comparable to the hours the provider makes available for Medi-Cal services that are not covered by the Agreement or another County. 2. Appointments data, including wait times for requested services, must be recorded and tracked by Contractor, and submitted to the County on a monthly basis in a format specified by the County. Appointments' data should be submitted to the County's Quality Management Department or other designated persons. E-15 Revised Exhibit E 3. Urgent care appointments for services that do not require prior authorization must be provided to individual s within 48 hours of a request. Urgent appointments for services that do require prior authorization must be provided to clients within 96 hours of request. 4. Non-urgent non-psychiatry mental health services, including, but not limited to Assessment, Targeted Case Management, and Individual and Group Therapy appointments (for both adult and children/youth) must be made available to Medi-Cal individuals within 10 business days from the date the individual or a provider acting on behalf of the individual, requests an appointment for a medically necessary service. Non-urgent psychiatry appointments (for both adult and children/youth) must be made available to Medi-Cal individual s within 15 business days from the date the client or a provider acting on behalf of the individual, requests an appointment for a medically necessary service. 5. Applicable appointment time standards may be extended if the referring or treating provider has determined and noted in the individual's record that a longer waiting period will not have a detrimental impact on the health of the individual. 6. Periodic office visits to monitor and treat mental health conditions may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed mental health provider acting within the scope of their practice. c. PROVIDER APPLICATION AND VALIDATION FOR ENROLLMENT (PAVE) i. Contractor shall ensure that all of its required clinical staff, who are rendering SMHS to Medi-Cal individuals on behalf of Contractor, are registered through DHCS' Provider Application and Validation for Enrollment (PAVE) portal, pursuant to BHIN 20- 071 requirements, the 21st Century Cures Act and the CMS Medicaid and Children's Health Insurance Program (CHIP) Managed Care Final Rule. ii. SMHS licensed individuals required to enroll via the "Ordering, Referring and Prescribing" (ORP) PAVE enrollment pathway (i.e. PAVE application package) available through the DHCS PED Pave Portal, include: Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), Psychologist, Licensed Educational Psychologist, Physician (MD and DO), Physician Assistant, Registered Pharmacist/Pharmacist, Certified Pediatric/Family Nurse Practitioner, Nurse Practitioner, Occupational Therapist, and Speech-Language Pathologist. Interns, trainees, and associates are not eligible for enrollment. E-16 Revised Exhibit E d. PHYSICIAN INCENTIVE PLAN i. If Contractor wants to institute a Physician Incentive Plan, Contractor shall submit the proposed plan to the County which will in turn submit the Plan to the State for approval, in accordance with the provisions of 42 C.F.R. § 438.6(c). 5. DATA, PRIVACY AND SECURITY REQUIREMENTS a. ELECTRONIC PRIVACY AND SECURITY i. Contractor shall have a secure email system and send any email containing PII or PHI in a secure and encrypted manner. Contractor's email transmissions shall display a warning banner stating that data is confidential, systems activities are monitored and logged for administrative and security purposes, systems use is for authorized users only, and that users are directed to log off the system if they do not agree with these requirements. ii. Contractor shall institute compliant password management policies and procedures, which shall include but not be limited to procedures for creating, changing, and safeguarding passwords. Contractor shall establish guidelines for creating passwords and ensuring that passwords expire and are changed at least once every 90 days. iii. Any Electronic Health Records (EHRs) maintained by Contractor that contain PHI or PII for individuals served through this Agreement shall contain a warning banner regarding the PHI or PII contained within the EHR. Contractors that utilize an EHR shall maintain all parts of the clinical record that are not stored in the EHR, including but not limited to the following examples of client signed documents: discharge plans, informing materials, and health questionnaire. iv. Contractor entering data into any County electronic systems shall ensure that staff are trained to enter and maintain data within this system. 6. PROGRAM INTEGRITY a. Credentialing and Re-credentialing of Providers i. Contractor shall ensure that all of their network providers delivering covered services, sign and date an attestation statement on a form provided by County, in which each provider attests to the following: 1. Any limitations or inabilities that affect the provider's ability to perform any of the position's essential functions, with or without accommodation; 2. A history of loss of license or felony convictions; 3. A history of loss or limitation of privileges or disciplinary activity; 4. A lack of present illegal drug use; and 5. The application's accuracy and completeness E-17 Revised Exhibit E ii. Contractor must file and keep track of attestation statements, credentialing applications and credentialing status for all of their providers and must make those available to the County upon request at any time. iii. Contractor is required to sign an annual attestation statement at the time of Agreement renewal in which they will attest that they will follow County's Credentialing Policy and MHSUDS IN 18-019 and ensure that all of their rendering providers are credentialed as per established guidelines. E-18