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Home My WebLink AboutAgreement A-17-152 with DHCS.pdfPage 2 ALLOCATION AGREEMENT MEDI-CAL OUTREACH AND ENROLLMENT COUNTY OF FRESNO State of California – Department of Health Care Services TERMS AND CONDITIONS OF ALLOCATION The County shall be responsible for the performance of the work as set forth herein below and for the preparation of deliverables and reports as specified in this Agreement. The County's Project Representative shall promptly notify the State of events or proposed changes that could affect the Work Plan under this Agreement. Special Provisions 1. County shall complete all work in accordance with an approved Work Plan which will be included in this Agreement as Attachment 2. 2. Rights in Data and Reporting: The County agrees that all data and reports produced in the performance of this Agreement are subject to the rights of the State as set forth in this section. The State shall have the right to reproduce, publish, and use all such data and reports, or any part thereof, in any manner and for any purposes whatsoever and to authorize others to do so. General Provisions A. Definitions 1. The term “Allocation” as used herein means the Outreach and Enrollment Allocation funding authorized by AB 82, Section 71. 2. The term “Agreement” as used herein means an allocation agreement between the State and County specifying the payment of Allocation Amount by the State for the performance of Work Plan within the Project Performance Period by the County. 3. The term “County” as used herein means the party described as the County on page one (1) of this Agreement. 4. The term “Allocation Amount” as used herein means funds awarded to the County by the State. 5. The term “Project Performance Period” as used herein means the period of time that the Allocation Amount is available as described on page one (1) of this Agreement. 6. The term "Project Representative" as used herein means the person authorized by the County to be responsible for the Allocation and is capable of making daily management decisions. 7. The term “State” as used herein means the Department of Health Care Services. 8. The term “Community Based Organization,” or “CBO,” as used herein means a public or private nonprofit organization of demonstrated effectiveness that is representative of a community or significant segments of a community, and provides educational or related services to individuals in the community, as stated in 20 U.S.C.A § 7801(6). Page 3 B. Allocation Execution 1. County agrees to complete the Allocation in accordance with the time of the Allocation Performance Period and under the terms and conditions of this Agreement. 2. County shall comply with the provisions of AB 82, Section 71. 3. County agrees to submit in writing any deviation from the attached Work Plan to the State for approval prior to implementation of changes. C. Allocation Costs Subject to the availability of Allocation Amount, the State hereby grants to the County an additional $116,129 to the previous allocated amount of $893,431.35 not to exceed the amount stated on page one (1) of this Agreement in consideration of and on condition that the sum be expended in carrying out the purpose as set forth in the Work Plan and under the terms and conditions set forth in this Agreement. The Allocation Amount to be provided to the County, under this Agreement, may be disbursed as follows: 1. To Community Based Organizations (CBOs): County shall disperse at least 50% of the Allocation Amount The County is required to partner with one or more CBOs to develop, conduct and implement effective tools and methods to expand Medi-Cal outreach, increase Medi-Cal enrollment and contribute efforts to retention for the uninsured, targeted populations. The County is not required to immediately contract with CBOs in light of the timelines that may be necessary for contracting processes. However, the County will need to demonstrate through quarterly reporting activities on the progress of contracting with CBOs. 2. Indirect administrative costs, including planning, plan documentation, and other administrative costs shall not exceed 10% of the Allocation Amount. D. Payment Documentation 1. All payment requests must be submitted by the County on a quarterly basis using a completed Outreach and Enrollment Quarterly Invoice, Attachment 3. The invoice and the deliverables noted below must accompany the invoice as outlined in the Quarterly Invoice, Deliverables and Payment Schedule noted on Page 4. Budget Plan, Attachment 1 Work Plan, Attachment 2 Outreach and Enrollment Quarterly Invoice, Attachment 3 Quarterly Progress Report, Attachment 4 Annual Budget Report, Attachment 5 2. County shall submit all documentation for Allocation completion and final reimbursement within 90 days of Allocation completion, but no later than the end of the Project Performance Period as shown on page one (1). 3. Payments shall be on the basis of costs incurred. 4. Advance Allocation payment without an invoice is not allowed. Page 4 QUARTERLY INVOICE, DELIVERABLES AND PAYMENT SCHEDULE 2016 / 2017 / 2018 DUE DATE OF DELIVERABLES COUNTY DELIVERABLES QUARTER FOR INVOICING EXPENDITURES DHCS REVIEW DEADLINE *ESTIMATED PAYMENT DATE 01/05/16 INVOICES/ PROGRESS REPORT October, November, December 2015 01/11/16 02/01/16 04/05/16 INVOICES/ PROGRESS REPORT January, February, March 2016 04/11/16 05/02/16 07/07/16 3rd ANNUAL BUDGET REPORT / INVOICES/ PROGRESS REPORT April, May, June 2016 07/13/16 08/03/16 10/03/16 INVOICES/ PROGRESS REPORT July, August, September 2016 10/10/16 10/30/16 01/06/17 INVOICES/ PROGRESS REPORT October, November, December 2016 01/12/17 02/02/17 04/07/17 INVOICES/ PROGRESS REPORT January, February, March 2017 04/13/17 05/04/17 07/07/17 4th ANNUAL BUDGET REPORT / INVOICES/ PROGRESS REPORT April, May, June 2017 07/13/17 08/03/17 10/06/17 INVOICES/ PROGRESS REPORT July, August, September 2017 10/12/17 11/04/17 01/05/18 INVOICES/ PROGRESS REPORT October, November, December 2017 01/11/18 02/01/18 04/05/18 INVOICES/ PROGRESS REPORT January, February, March 2018 04/11/18 05/02/18 07/07/18 5th ANNUAL BUDGET REPORT / INVOICES/ PROGRESS REPORT April, May, June 2018 07/13/18 08/03/18 *Based on 21 processing days for DHCS’ Accounting and the State Controller’s Office. Budget Plan County is required to use the Budget Plan, Attachment 1. As outlined in the Quarterly Invoice, Deliverables and Payment Schedule above, a Budget Plan must be submitted to DHCS in order to receive the initial payment allocation of at least 20% of the Total Allocation Award. Work Plan County is required to use the Work Plan, Attachment 2. As outlined in the Quarterly Invoice, Deliverable and Payment Schedule noted above, a Work Plan must be submitted to DHCS in order to receive the second quarterly payment. The Work Plan shall include strategies, milestones, and time frames for outreach, enrollment and retention activities completed by the County and its contracted CBOs. Outreach and Enrollment Quarterly Invoice County is required to use the Outreach and Enrollment Quarterly Invoice, Attachment 3. Invoices must be submitted by the County on a quarterly basis as outlined in the Quarterly Payment and Deliverable Schedule noted above. The Invoice must include detailed budget activity and expenditures for the specific quarter. Please note: To receive the initial payment allocation of at least 20% of the Total Allocation Award, County must submit a Budget Plan and an Invoice. The Invoice will reflect the time needed to develop the Budget Plan. Page 5 Quarterly Progress Report County is required to submit a Quarterly Progress Report, Attachment 4. As outlined in the Quarterly Invoice, Deliverables and Payment Schedule noted above, Quarterly Progress reports will be required starting with the third quarter reporting period. The County must provide a progress report to measure and document progress-to-date on the work plan objectives and performance goals. The State reserves the right to require reports more frequently than on a quarterly basis if necessary, but no more than once a month. Annual Budget Report County is required to submit an Annual Budget Report, Attachment 5, at the end of every State fiscal year as outlined in the following schedule:  Due July 15, 2016 – Report period July 1, 2015 through June 30, 2016  Due July 14, 2017 – Report period July 1, 2016 through June 30, 2017  Due July 13, 2018 – Report period July 1, 2017 through June 30, 2018 E. Allocation Termination or Withdrawal 1. County may withdraw from the Outreach and Enrollment Allocation Funding by notifying the State in writing at any time of the request to withdraw from further participation. Once the withdraw request is received, the State will contact the County to complete close out tasks. 2. County may unilaterally rescind this Agreement at any time prior to the commencement of the Allocation. After Allocation commencement this Agreement may be rescinded, modified or amended by mutual agreement in writing. 3. Failure by the County to comply with the terms of this Agreement may be cause for terminating all obligations of the State for additional Allocation payments. F. Loss of Allocation Amount The following actions may result in a loss or part of all Allocation Amount allocated to the County. 1. A County fails to return a signed Agreement to DHCS within 60 days of receipt of the Agreement. 2. A County fails to produce satisfactory Invoices and Deliverables as outlined in the Quarterly Invoice and Deliverable Schedule noted on Page 5. 3. A County withdraws from the Allocation Agreement. 4. A County fails to submit a satisfactory Corrective Action Plan (CAP). i. This action shall result in a 50% reduction of the total Allocation Amount. G. Hold Harmless 1. County agrees to waive all claims and recourse against the State including the right to contribution for loss or damage to persons or property arising from, growing out of or in any way connected with or incident to this Agreement except claims arising from the concurrent or sole negligence of State, its officers, agents, and employees. 2. County agrees to indemnify, hold harmless an defend the State, its officers, agents and employees against any and all claims, demand costs, expenses or liability costs arising out of legal actions pursuant to items to which the County has certified. County acknowledges that it is solely responsible for compliance with items to which it has certified. Page 6 H. Financial Records 1. County agrees to maintain satisfactory financial accounts, documents and records for the Allocation and to make them available to the State for auditing at reasonable times. County also agrees to retain such financial accounts, documents and records for three years following Allocation termination or completion. 2. County and State agree that during regular office hours each of the parties hereto and their duly authorized representative shall have the right to inspect and make copies of any books, records or reports of the other party pertaining to this Agreement or matters related thereto. County agrees to maintain and make available for inspection by the State accurate records of all of its costs, disbursements and receipts with respect to its activities under this Agreement. 3. County agrees to use a generally accepted accounting system. I. Community Based Organizations (CBOs) 1. As mandated in AB 82, Section 71(e)(1), “The funds allocated under this section shall be used only for the Medi-Cal outreach and enrollment activities and may supplement, but shall not supplant, existing local, state, and foundation funding of county outreach and enrollment activities.” 2. AB 82, Section 71(g), requires that “Under terms of the approved allocation for the outreach and enrollment program, funded entities under this section shall not receive payment for in- person assister payments for assisting potential Medi-Cal enrollees.” 3. In working with the CBOs for Medi-Cal outreach and enrollment, the counties will need to provide documentation clearly delineating how their partnering CBOs will separate the enrollment work under this allocation from the enrollment work of the CBO’s Certified Enrollment Counselors (CECs) and Certified Insurance Agents (CIAs) for which they would be paid $58 per enrolled application. i. Example: If a CBO, in partnership with a county agency through this funding source, sends out a CEC to an outreach and enrollment activity at a substance use disorder clinic and enrolls some of the population at the clinic or makes an appointment with them and enrolls them later, the CBO cannot claim the $58 per approved Medi-Cal application for this same person. The CBO is already receiving funds for this purpose through the county. J. Audit 1. Allocations are subject to audit by the State for three years following the final payment of Allocation Amount. The purpose of this audit is to verify that Allocation expenditures were properly documented. Counties will be contacted at least 30 days in advance of an audit. 2. Audit will include all books, papers, accounts, documents, or other records of the County, as they relate to the Allocation for which the State authorized Allocation Amount. The County shall have the Allocation records, including the sources documents and cancelled warrants, readily available to the State. 3. County must also provide an employee having knowledge of the Allocation and the accounting procedure or system to assist the State's auditor. The County shall provide a copy of any document, paper, record, or the like requested by the State. 4. All Allocation records must be retained for at least one year following an audit or final disputed audit findings. Page 7 K. Nondiscrimination 1. County shall not discriminate against any person on the basis of sex, race, color, national region, age, religion, ancestry, or physical handicap when conducting outreach and enrollment efforts pursuant to this Agreement and in compliance with the Americans with Disabilities Act. 2. County shall ensure the security, privacy and confidentiality of each enrollee. L. Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) 1. Counties shall ensure security of privacy and confidentiality of each consumer application and comply with HIPAA requirements as set forth by law. M. Federal Funding 1. The full Allocation Agreement fund amount is contingent upon State dollars being matched with federal funds. If sufficient federal funding for the current year and/or any subsequent year covered under this Agreement is not received to pay for the federally funded portion of the program, DHCS will not be liable for paying the federal portion to the counties under this Agreement and the counties shall not be obligated to perform any provisions of this Agreement. If funding for any fiscal year is reduced or deleted by the Budget Act for purposes of this program, DHCS shall have the option to cancel this Agreement with no liability occurring to DHCS, or offer an Agreement amendment to the counties to reflect the reduced amount. Department of Health Care Services Attachment 1 Page 1 of 2 (COUNTY) MEDI-CAL OUTREACH & ENROLLMENT BUDGET PLAN •List all personnel positions and the corresponding time base for each staff member (i.e. full time = 1.0, half time = .50). •Identify the projected budget amount for each line item per fiscal year and the projected total amounts. •Identify the costs of benefits for each fiscal year and project the total amount. •List all non-personnel expenses which may include, but not limited to, operating costs, program supplies, travel, technology equipment, and subcontractors. •Provide a projection for each fiscal year and the total projected amounts. Please identify your specific timeframes of your contract per fiscal year, modify if necessary (i.e. Fiscal Year 1 = 03/01/14 – 06/30/14; Fiscal Year 2 = 07/01/14 – 06/30/15; Fiscal Year 3 = 07/01/15 – 02/28/16). Furthermore, for each fiscal year of your contract, include total costs and overall costs for Total Personnel, Total Non-Personnel, Direct Costs (Projects: i.e. equipment specific for outreach and enrollment), and Indirect Costs (Overhead: i.e. health insurance) and identify the percentage, and the Grand Total amounts. Medi-Cal Outreach and Enrollment Budget (AB 82) Time Base FY 1 3/1/14 – 6/30/14 FY 2 7/1/14 – 6/30/15 FY 3 7/1/15 – 6/30/16 FY 4 7/1/16 – 6/30/17 FY 5 7/1/17 – 6/30/18 Total Amounts Personnel Staff - $ $ $ $ $ $ - $ $ $ $ $ $ - $ $ $ $ $ $ - $ $ $ $ $ $ - $ $ $ $ $ $ - $ $ $ $ $ $ Benefits $ $ $ $ $ $ Total Personnel Expenses $N/A $ N/A $ N/A $ N/A $ N/A $ N/A Non-Personnel – Direct Costs -Office Expenses $ $ $ $ $ $ -Equipment $ $ $ $ $ $ -Travel $ $ $ $ $ $ -Training $ $ $ $ $ $ -Conference/Meetings $ $ $ $ $ $ Department of Health Care Services Attachment 1 Page 2 of 2 -Outreach Material $ $ $ $ $ $ -Total Budget for All CBOs $ $481,408.45 $260,562.55 $246,460 $21,129 $1,009,560 -Other Costs [itemize expenses in an attachment] $ $ $ $ Total Direct Costs $N/A $481,408.45 $260,562.55 $246,460 $21,129 $1,009,560 Non-Personnel – Indirect Costs -Health Insurance $ $ $ $ $ $ -Other Costs [itemize expenses in an attachment] $ $ $ Total Indirect Costs $N/A $ N/A $ N/A $N/A $$N/A $N/A Total Personnel Expenses $N/A $N/A $N/A $N/A $N/A $N/A Total Direct Costs $N/A $481,408.45 $260,562.55 $246,460 $21,129 $1,009,560 Total Indirect Costs @ 10% $N/A $ $ $ $ $ Grand Total $N/A $481,408.45 $260,562.55 $246,460 $21,129 $1,009,560 Department of Health Care Services COUNTY OF FRESNO OUTREACH & ENROLLMENT WORK PLAN Attachment 2 Activity 1 – Program Planning and Startup Activity 1: Identify major O&E planning and startup milestones, strategies, and activities. Identify the AB 82 population groups each effort will target and for each targeted group (e.g., persons with mental health disorder needs, persons with substance use disorder needs, homeless, young men of color, persons in jails, prison, parole probation or post release community supervision, families of mixed immigration, and person with limited English proficiency), how many you intend to enroll (i.e. Increase the number of Medi-Cal eligible clients targeted by O&E efforts by X). MILESTONE: For each objective, list each partner separately and indicate the number of individuals that they plan to enroll into Medi-Cal. DESCRIPTION OF STRATEGY/ACTIVITY: Describe below what and or how each partner plans on achieving their goals that are identified in the adjacent milestones. What methods/means will be used to achieve these goals and objectives? MILESTONES STRATEGIES/ACTIVITIES AB 82 POPULATION GROUP(S) TIMELINE WHO IS RESPONSIBLE Program Planning Hold meetings with contracted CBOs to discuss contract objectives, outcome measures, invoice and activity report requirements, and allowable/non allowable activities. 1 through 7 3/12/14 – 6/30/18 County Staff Analyst Program Strategies Have CBOs collaborate with each other and the County to develop and share strategies to increase renewal activities. County staff and CBO staff from North Star Family Center, Centro La Familia Advocacy Services, Inc., Clinica Sierra Vista, Fresno Center for New Americans, Fresno Healthy Communities Access Partners, Fresno Interdenominational Refugee Ministries, Reading and Beyond, United Health Care Centers, West Fresno Family Resource Center, Youth Center of America, and any newly contracted CBOs. Program Activities CBOs will host or attend community events where they will help clients complete their applications. CBOs will also provide renewal education so clients will be aware of the renewal process and know when their renewal is due to prevent termination. CBO Training County will teach and inform CBOs of new legislation and changes in Medi- Cal requirements. 3/12/14 – 6/30/18 County Staff Analyst or Social Services Program Supervisor/Program Specialist. Department of Health Care Services COUNTY OF FRESNO OUTREACH & ENROLLMENT WORK PLAN Attachment 2 MILESTONES STRATEGIES/ACTIVITIES LOCATION TARGET POPULATION AND NUMBER OF ENROLLEMENTS TIMELINE WHO IS RESPONSIBLE Outreach: provide outreach to approximately 1,000 to 1,500 residents each month. Employ outreach activities such as the following: • distribute flyers, • organize enrollment events, • collaborate with media outlets, and religious institutions, • provide educational seminars, and • other various activities. Activities will occur at CBO offices and various community locations throughout the county. Locations will vary. 1 through 7; numbers per categories will vary. 3/12/14 – 6/30/18 CBO staff from North Star Family Center, Centro La Familia Advocacy Services, Inc., Clinica Sierra Vista, Fresno Center for New Americans, Fresno Healthy Communities Access Partners, Fresno Interdenominational Refugee Ministries, Reading and Beyond, United Health Care Centers, West Fresno, Youth Center of America, and any newly contracted CBOs. Complete an average of 400 applications per month. Attend or host community events to inform the community of Medi- Cal enrollment assistance. Develop a presence in the community and targeted population so that clients will know to seek CBO for assistance. Activity 2 – Outreach and Enrollment Activities Activity 2: Identify major O&E activities. Identify the AB 82 population groups each effort will target and for each targeted group (e.g., persons with mental health disorder needs, persons with substance use disorder needs, homeless, young men of color, persons in jails, prison, parole probation or post release community supervision, families of mixed immigration, and person with limited English proficiency), how many you intend to enroll (i.e. Increase the number of Medi-Cal eligible clients targeted by O&E efforts by X). MILESTONE: For each objective, list each partner separately and indicate the number of individuals that they plan to enroll into Medi-Cal. DESCRIPTION OF STRATEGY/ACTIVITY: Describe below what and or how each partner plans on achieving their goals that are identified in the adjacent milestones. What methods/means will be used to achieve these goals and objectives? Activity 3 – Retention Department of Health Care Services COUNTY OF FRESNO OUTREACH & ENROLLMENT WORK PLAN Attachment 2 MILESTONES STRATEGIES/ACTI VITIES LOCATION TARGET POPULATION AND NUMBER OF ENROLLEMENTS TIMELINE WHO IS RESPONSIBLE Conduct Medi-Cal retention efforts for residents enrolled in Medi-Cal Provide materials at Medi-Cal Outreach and Enrollment events reminding residents to renew their coverage. Activities will occur at CBO offices and various community locations throughout the county. Locations will vary. 1 through 7, numbers per categories will vary. 3/12/14 – 6/30/18 CBO staff from North Star Family Center, Centro La Familia Advocacy Services, Inc., Clinica Sierra Vista, Fresno Center for New Americans, Fresno Healthy Communities Access Partners, Fresno Interdenominational Refugee Ministries, Reading and Beyond, United Health Care Centers, West Fresno Family Resource Center, Youth Center of America, and any newly contracted CBOs. Educate newly enrolled clients. Educate clients on the renewal process to help them retain their Medi-Cal. During community events, inquire if clients are aware of Medi-Cal renewals. Encourage clients to check with the Department of Social Services IVR System on a regular basis to ensure their benefits do not lapse. Activity 3: Identify major O&E retention activities. Identify the AB 82 population groups each effort will target and for each targeted group (e.g., persons with mental health disorder needs, persons with substance use disorder needs, homeless, young men of color, persons in jails, prison, parole probation or post release community supervision, families of mixed immigration, and person with limited English proficiency), how many you expect to re-enroll (i.e. Increase the number of targeted Medi-Cal enrollees who retain their Medi-Cal eligibility by X). MILESTONE: For each objective, list each partner separately and indicate the number of individuals that they plan to retain into Medi-Cal. DESCRIPTION OF STRATEGY/ACTIVITY: Describe below what and or how each partner plans on achieving their goals that are identified in the adjacent milestones. What methods/means will be used to achieve these goals and objectives? Activity 4 – Tracking and Reporting Activity 4 : Identify your intent and list the AB 82 population groups that you will contract to target. Identify for each targeted group, how many you intend to enroll (i.e. Increase the number of Medi-Cal eligible clients in XXX County who receive outreach, education and information regarding the AB 82 targeted populations (e.g., persons with mental health disorder needs, persons with substance use disorder needs, homeless, young men of color, persons in jails, prison, parole probation or post release community supervision, families of mixed immigration, and person with limited English proficiency). Department of Health Care Services COUNTY OF FRESNO OUTREACH & ENROLLMENT WORK PLAN Attachment 2 STRATEGIES/ACTI VITIES LOCATION TARGET POPULATION AND NUMBER OF ENROLLEMENTS TIMELINE WHO IS RESPONSIBLE CBOs will submit applications through mybenefitscalwin. Mybenefitscalwin has a tracking feature that logs the number of applications submitted. CBOs will also track applications manually to be use as backup documentation if an issue arises. Services will be provided at CBO’s office location as well at various community events. 1 through 7, numbers per categories will vary. 3/12/14 – 6/30/18 County staff and CBO staff from North Star Family Center, Centro La Familia Advocacy Services, Inc., Clinica Sierra Vista, Fresno Center for New Americans, Fresno Healthy Communities Access Partners, Fresno Interdenominational Refugee Ministries, Reading and Beyond, United Health Care Centers, West Fresno Family Resource Center, Youth Center of America, and any newly contracted CBOs. Mybenefitscalwin tracks applications in the following status: Pending, approved, and denied. Mybenefitscalwin will ensure CBOs maintain 65% approval rate and will decrease their compensation proportionally if they do not maintain the approval rate. The County will also use CalWIN generated reports and CBOs’ paper tracking sheet to check for approvals if there is a discrepancy. CBOs will track the number of community events they attend or host. CBOs will estimate the number of AB 82 populations during each community events. Although CBOs are free to enroll clients from all AB82 populations, CBOs do focus on specific clientele. Please see attachment A. MILESTONE: For each objective, list each partner separately and indicate the number of individuals that they plan to enroll into Medi-Cal. DESCRIPTION OF ACTIVITY: Describe below what and or how each partner plans on achieving their goals that are identified in the adjacent milestones. What methods/means will be used to achieve these goals and objectives? Beginning & Ending Dates: Identify the timeframe for each partner to achieve their goals and objectives. Department of Health Care Services Attachment 3 County: Authorization #: Fiscal Year: Invoice #: FY Qtr: Date: BUDGET CATEGORIES (per contract) Approved Budget Prior Amount Expended Expenses Billed this Quarter Adjustment Approved Amount Amount Expended to Date Remaining Balance PERSONNEL EXPENSES Full-Time Staff Part-Time Staff Benefits % TOTAL PERSONNEL EXPENSES OPERATING EXPENSES -$ -$ Office Expenses -$ -$ Equipment -$ -$ Travel -$ -$ Training -$ -$ Conferences/Meetings -$ -$ Outreach Materials -$ -$ Other Costs [itemize each expense]-$ -$ Total Budget for all CBO's -$ -$ Deliverables of Work Plan and Budget Plan -$ -$ Indirect Costs %*-$ -$ -$ -$ -$ -$ -$ -$ TOTAL OPERATING EXPENSES -$ -$ Page 1 of 2 AB 82 Sec. 71 Outreach & Enrollment Quarterly Invoice * Cannot exceed 10% of total funds allocated DHCS use only BUDGET CATEGORIES (per contract) Approved Budget Prior Amount Expended Expenses Billed this Quarter Adjustment Approved Amount Amount Expended to Date Remaining Balance DHCS use only OTHER EXPENSES - - - - - - - - - - TOTAL OTHER EXPENSES - - - TOTAL OF ALL EXPENSES County Project Financial Officer (print) County Project Director (print) Please submit invoices from CBOs if applicable. O&E Q invoice (01/15)Page 2 of 2 Sign in blue ink only AB 82 SEC. 71. (a) (1) The State Department of Health Care Services shall accept funding from private foundations in the amount of at least $12.5 million to provide allocations for the management and funding of Medi-Cal outreach and enrollment plans specific to the provisions contained in this section. (2) The department shall seek necessary federal approval for purposes of obtaining federal funding for activities conducted under this section. Signature Date _____________________________ Signature Date _____________________________ Sign in blue ink only I certify that the expenditures claimed represent actual expenses for the service performed under this allocation. Department of Health Care Services Attachment 4 Page 1 of 5 O&E Quarterly Progress Report Outreach, Enrollment, and Retention County: _________ Quarter: ________ Instructions: Report the progress your county achieved during the quarter and year-to-date (YTD) towards each work plan objective. This report is comprised of a brief narrative and completion of the chart described below for each O&E objective. Narrative (2-10 pages depending on the complexity of your O&E efforts): • Describe the activities carried out this reporting period to meet the objectives, as described in your work plan. Briefly describe indicators or benchmarks used and progress to date. If you worked with any community-based organizations (CBOs), please indicate who they are and what did they do for the project. o What did you accomplish during this reporting period? Did you use indicators or benchmarks to determine your progress? How many Medi-Cal enrollments resulted from your Medi-Cal O&E efforts? • Describe any practices or innovative strategies that were successful and can serve as a model for others or that your county can build upon. • Describe project activities or successes not identified in the work plan that were a spin off of work plan activities. • Describe which, if any, proposed activities were not completed. o If the activities completed differ from your proposal, what caused these changes? Were activities delayed and if so, why? Will these activities be completed? When and how? Are there any activities you will not be able to complete during the course of your grant? • Describe any products developed and data sources used. • Describe AB 82 population group impacted by your O&E efforts. • Describe any challenges or barriers encountered and proposed solutions. • Describe whether your department/agency or partnering organizations received funding from other foundations, corporations, or government bodies for the Medi-Cal O&E efforts currently being supported by this allocation funding opportunity. • If applicable, please give each funder’s name, the amount of funding provided, and when it was provided. If the support is in-kind and you can estimate the dollar amount, provide that figure; if it is in- kind and you cannot estimate the amount, do not include it. • Describe whether DHCS assisted or failed to assist you in any way during this time period. Department of Health Care Services Attachment 4 Page 2 of 5 o Have DHCS’ instructions and messages been consistent or have you gotten different messages from different DHCS staff? • If you chose to do so, describe anything else you would like to share with DHCS pertaining to this Medi- Cal O&E initiative. o Please include an addendum to the report, if needed. Feel free to tell us about any other unexpected issues, concerns, or successes you have had during this reporting period. Exhibit 1 • Using your approved work plan as a blueprint, discuss the progress made on each of your objectives. Quantify your progress whenever possible (e.g., number of people enrolled, enrollment percentages, etc.). • Indicate whether the information provided in this attachment pertains to Outreach, Enrollment, Retention, or any combination of the three, efforts accomplished or attempted during the reporting period. Exhibit 2 • Provide information for all items that apply to the progress made during the current quarter. • Provide year-to-date totals. Department of Health Care Services Attachment 4 Exhibit 1 Page 3 of 5 O&E Quarterly Progress Report Template Outreach, Enrollment, and Retention County: Reporting Period: Check the appropriate box to identify the O&E objective (you may check one or more box below): Outreach Enrollment Retention Major Deliverables and Activities AB 82 Target Population Reached Materials Staff and/or CBO’s Used Status Performance Measures and Data Collection . O&E Quarterly Progress Report Template Department of Health Care Services Attachment 4 Exhibit 1 Page 4 of 5 Outreach, Enrollment, and Retention County: Reporting Period: Check the appropriate box to identify the O&E objective (you may check one or more box below): Outreach Enrollment Retention Major Deliverables and Activities AB 82 Target Population Reached Materials Staff and/or CBO’s Used Status Performance Measures and Data Collection Department of Health Care Services Attachment 4 Exhibit 2 Page 5 of 5 O&E Quarterly Progress Report Outreach, Enrollment, and Retention County: _________ Quarter: _________ Numbers Specific to O&E Activities ONLY Current Quarter Year-to-date Amount Billed Number of AB 82 individuals reached by O&E efforts Number of AB 82 individuals assisted with enrollment into Medi-Cal Number of approved Medi-Cal applications resulting from Medi-Cal O&E efforts Number of AB 82 beneficiaries assisted with annual eligibility review (AER) and/or Medi-Cal redetermination Number of AB 82 beneficiaries that retained Medi-Cal coverage as a result of the O&E efforts Number of CEC’s and CIA’s used in O&E efforts Number of CAAs used in O&E efforts Department of Health Care Services Attachment 5 Page 1 of 1 The County of Fresno Annual Budget Report Fiscal Year 2 (01/01/2017 through 12/31/2017) Personnel [Itemize all expenses] Position Title # of Staff Monthly Salary Range FTE % Annual Cost __________________________ ____ $XXX,XXX - $XXX,XXX ___% $ __________________________ ____ $XXX,XXX - $XXX,XXX ___% $ __________________________ ____ $XXX,XXX - $XXX,XXX ___% $ Total Salary $ Fringe Benefits (____%) $ Total Personnel $ 0 Office Expenses [Itemize all expenses] ____________________________________ $______ ____________________________________ $______ ____________________________________ $______ ____________________________________ $______ Total Operating Expenses $ 0 Equipment [Itemize equipment expenses i.e., items with a Unit cost of $5,000 or more] ____________________________________ $______ ____________________________________ $______ Total Equipment Expenses $ 0 Travel Total Travel $ 0 Community-Based Organizations (CBOs) [List all CBOs and their itemized budgets, add additional CBOs as necessary] CBO Name: __________________________________________________________________________________________ Personnel Office Expenses Travel Equipment Indirect Costs Other Costs Total Costs $_______ $____________ $_______ $________ $________ $________ $_________ Total CBOs $ Other Costs [Itemize each expense] ____________________________________ $________ ____________________________________ $________ Total Other Costs $ 0 Indirect Costs [Itemize each expense] Total Indirect Costs $ 0 ____________________________________ $________ ____________________________________ $________ Annual Budget Total $