HomeMy WebLinkAboutAgreement A-18-690 with Drug Medi-Cal.pdf1
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AGREEMENT
Agreement No . 18-690
3 THIS AGREEMENT is made and entered into this 11th day of December, 2018 , by and between
4 the COUNTY OF FRESNO , a Political Subdivis ion of the State of California , hereinafter referred to as
5 "COUNTY", and each Contractor listed in Exhibit A , "DMC Services Vendor List ," attached hereto and by
6 this reference incorporated herein , collectively herein after referred to as "CONTRACTOR", and such
7 additional CONTRACTOR as may, from time to time during the term of this Agreement , be added by
8 COUNTY. Reference in this Agreement to "party " or "parties " shall be understood to refer to COUNTY and
9 each CONTRACTOR , unless otherwise specified .
10 WITNESS ETH:
11 WHEREAS , COUNTY is authorized through its Intergovernmental Agreement with the California
12 Department of Health Care Services , hereinafter referred to as State or DHCS , to subcontract for Drug
13 Medi-Cal services in Fresno County ; and
14 WHEREAS , CONTRACTOR(S) are certified by the State to provide services required by the
15 COUNTY , pursuant to the terms and conditions of this Agreement.
16 NOW, THEREFORE , in consideration of the mutual covenants , terms and conditions herein
17 contained , the parties hereto agree as follows:
1. SERVICES 18
19 A. CONTRACTOR shall provide Drug Medi-Cal substance use disorder treatment
20 serv ices at State certified locations to eligible beneficiaries of Fresno County, as identified in this
21 Agreement, including all Exhibits , COUNTY's Request for Statement of Qualifications (RFSQ) # 18-064
22 dated July 3 , 2018 ; Addendum No . One (1) dated July 26 , 2018 ; and Addendum No . Two (2) dated August
23 10 , 2018 , hereinafter collectively referred to as COUNTY Revised RFSQ #18 -064 , and CONTRACTOR 's
24 response to said RFSQ #18-064 , dated August 15 , 2018 , all incorporated herein by reference and made
25 part of th is Agreement.
26 B . In the event of any inconsistency among these documents, the inconsistency shall
27 be resolved by giving precedence in the following order of priority : 1) to this Agreement , including any
28 Exhibits and amendments attached hereto but excluding RFSQ # 18-064 and the Response to the Revised
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RFSQ; 2) to the Revised RFSQ # 18-064, and; 3) to the Response to the Revised RFSQ. A copy of
COUNTY’s Revised RFSQ #18-064, and CONTRACTOR’s response shall be retained and made available
during the term of this Agreement by COUNTY’s Purchasing Division.
C. CONTRACTOR shall provide services as described in Exhibit B, Modality of Service
Descriptions, attached hereto and incorporated by this reference.
D. CONTRACTOR shall comply with requirements stated within the Intergovernmental
Agreement as listed in Exhibit C, Drug Medi-Cal Specific Requirements, attached hereto and by this
reference incorporated herein; and with all other provisions set forth in the Intergovernmental Agreement,
made available by the Department of Behavioral Health (DBH), Contracts Division - Substance Use
Disorder (SUD) Services at the following web address and by this reference incorporated herein:
https://www.co.fresno.ca.us/departments/behavioral-health/substance-use-disorder-services/provider-page.
CONTRACTOR is referred to therein as “Subcontractor” and COUNTY is referred to therein as
“Contractor.”
E. CONTRACTOR shall comply with the Fresno County Substance Use Disorder
(FCSUD) Provider Manual, herein after referred to as the “Provider Manual” and by this reference
incorporated herein, available at the DBH website at
https://www.co.fresno.ca.us/departments/behavioral-health/substance-use-disorder-services/provider-
page. No formal amendment of this agreement is required for changes to the Provider Manual to apply.
F. CONTRACTOR shall align program, services, and practices with the vision and
mission within Exhibit D, DBH Guiding Principles of Care Delivery, attached hereto and by this reference
incorporated herein. Contractor may be required to utilize and integrate clinical tools such as Reaching
Recovery at DBH’s discretion.
G. CONTRACTORs serving beneficiaries referred by Drug Court or Probation shall
carry out the following:
1) Comply with reporting requirements of Court or Probation relating to
beneficiary status change and treatment progress if an appropriate Release of Information (ROI) is in
place; and
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2) Conduct beneficiary intake within timeframes specified below from referral
or initial contact:
a) Outpatient within ten (10) days;
b) Narcotic Treatment Programs (NTP) within three (3) days; and
c) Residential services within forty-eight hours (48) hours.
H. CONTRACTOR shall maintain, at CONTRACTOR’s cost, a computer system
compatible with COUNTY’s current billing and electronic health record (EHR) system for the provision of
submitting information required under the terms and conditions of this Agreement. CONTRACTOR shall
complete billing and EHR data entry as follows: initial contact, when applicable; appointments; admissions;
ASAM level of care; discharge; and referrals.
I. CONTRACTOR’s staff will be required to attend meetings and trainings on an as-
needed basis, which may include but are not limited to, SUD treatment and fiscal trainings provided by the
State of California. Refer to the Provider Manual for a listing of required trainings.
2. ADDITIONS/DELETIONS OF CONTRACTOR(S)
COUNTY’s DBH Director or her designee reserves the right at any time during the term of
this Agreement to add new CONTRACTOR(S) to those listed in Exhibit A, “DMC Services Vendor List.” It
is understood any such additions will not affect compensation paid to the other CONTRACTOR(S), and
therefore such additions may be made by COUNTY without notice to or approval from other
CONTRACTOR(S) under this Agreement. These same provisions shall apply to the deletion of any
CONTRACTOR listed in Exhibit A, “DMC Services Vendor List,” except that deletions shall be made by
written mutual agreement between the COUNTY and the particular CONTRACTOR to be deleted, or shall
be in accordance with the provisions of Section Four (4), TERMINATION, of this Agreement.
3. TERM
The term of this Agreement shall be for a period of six (6) months, commencing on January
1, 2019 through and including June 30, 2019. This Agreement may be extended for three (3) additional
consecutive twelve (12) month periods upon written approval of both parties no later than thirty (30) days
prior to the first day of the next twelve (12) month extension period. The DBH Director or his or her
designee is authorized to execute such written approval on behalf of COUNTY based on CONTRACTOR’s
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satisfactory performance.
4. TERMINATION
A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided hereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated, at any time by giving the CONTRACTOR thirty (30) days advance written notice.
B. Breach of Contract - The COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of the COUNTY there is:
1) An illegal or improper use of funds;
2) A failure to comply with any term of this Agreement;
3) A substantially incorrect or incomplete report submitted to the COUNTY; or
4) Improperly performed service.
In no event shall any payment by the COUNTY constitute a waiver by the COUNTY of any
breach of this Agreement or any default which may then exist on the part of the CONTRACTOR. Neither
shall such payment impair or prejudice any remedy available to the COUNTY with respect to the breach or
default. The COUNTY shall have the right to demand of the CONTRACTOR the repayment to the
COUNTY of any funds disbursed to the CONTRACTOR under this Agreement, which in the judgment of
the COUNTY were not expended in accordance with the terms of this Agreement. The CONTRACTOR
shall promptly refund any such funds upon demand.
C. Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY upon the giving of thirty (30) days advance written notice of an
intention to terminate to CONTRACTOR.
D. Voluntary Termination of Intergovernmental Agreement - The COUNTY may
terminate its Agreement with DHCS at any time, for any reason, by giving sixty (60) days written notice
to DHCS. In the event the Intergovernmental Agreement is terminated, COUNTY may terminate this
contractor agreement. CONTRACTOR shall be paid for services provided to beneficiaries up to the
date of termination.
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5. COMPENSATION
A. COMPENSATION - In no event shall services performed under this Agreement be
in excess of annually negotiated reimbursement rates agreed upon by COUNTY and CONTRACTOR
during the term of this Agreement. It is understood that all expenses incidental to CONTRACTOR's
performance of services under this Agreement shall be borne by CONTRACTOR.
1) COUNTY shall reimburse non-NTP CONTRACTOR(S) the negotiated
contractor-specific rates as approved by DHCS, and incorporated herein as Exhibit E, “Fresno County
Drug Medi-Cal Rates for Fiscal Year 2018-19”, attached hereto and updated annually. Contractor rates
cannot exceed the DHCS-approved county maximum rates established in the annual fiscal plan.
2) COUNTY shall reimburse NTP CONTRACTOR(S) the lesser of the Unified
Statewide Monthly Reimbursement (USMR) rate or the CONTRACTOR’s usual or customary charge to
the public.
3) Payments by COUNTY shall be in arrears, for services provided during the
preceding month, within forty-five (45) days after receipt, verification and approval of CONTRACTOR’s
invoices by COUNTY’s DBH. If payment for services is denied or disallowed by State, and
subsequently resubmitted to COUNTY by CONTRACTOR, disallowed portion will be withheld from the
next reimbursement to CONTRACTOR until COUNTY has received reimbursement from State for said
services.
4) CONTRACTOR must accept, as payment in full, the amounts paid by
DHCS in accordance with the DMC-ODS STCs (Special Terms and Conditions) and the STCs’
Attachments. CONTRACTOR may not demand any additional payment from DHCS, client, or other
third party payers.
5) CONTRACTOR shall comply with 45 CFR 162.410(a)(1) for any subpart
that would be a covered health care provider if it were a separate legal entity. For purposes of this
paragraph, a covered health care provider shall have the same definition as set forth in 45 CFR
160.103. DHCS shall make payments for covered services only if CONTRACTOR is in compliance with
federal regulations.
B. COMPLIANCE – If CONTRACTOR should fail to comply with any provision of this
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Agreement, COUNTY shall be relieved of its obligation for further compensation. CONTRACTOR’s and
COUNTY’s obligations under this section shall survive the termination of this Agreement with respect to
services provided during the term of this Agreement without regard to the cause of termination of this
Agreement.
C. QUALITY ASSURANCE – For services rendered herein, CONTRACTOR shall
assure that an on-going quality assurance component is in place and is occurring. CONTRACTOR shall
assure that clinical records for each participant are of such detail and length that a review of said record
will verify that appropriate services were provided. If the record is unclear, incomplete, and/or indicates
that appropriate services were not provided, COUNTY reserves the right to withhold payment for the
applicable unit(s) of service.
D. PUBLIC INFORMATION – CONTRACTOR shall disclose its funding source in all
public information; however, this requirement of disclosure of funding source shall not be required in
spot radio or television advertising.
E. LOBBYING ACTIVITY – CONTRACTOR shall not directly or indirectly use any of
the funds provided under this Agreement for publicity, lobbying, or propaganda purposes designed to
support or defeat legislation pending before the Congress of the United States or the Legislature of the
State of California.
F. POLITICAL ACTIVITY – CONTRACTOR shall not directly or indirectly use any of
the funds under this Agreement for any political activity or to further the election or defeat of any
candidate for public office.
6. INVOICING
A. COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation at negotiated Drug Medi-Cal rates. CONTRACTOR shall enter billing information into the
COUNTY’s designated information system by the fifteenth (15th) of every month. Billing process shall be
in accordance with DBH DMC Billing Manual, and by this reference incorporated herein, available at the
DBH website at https://www.co.fresno.ca.us/departments/behavioral-health/substance-use-disorder-
services/provider-page. In addition to billing, CONTRACTOR shall submit on a monthly basis, an
Operational Expense Review, along with a general ledger, payroll register and supporting
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documentation for any line items CONTRACTOR’s assigned Analyst selects, per modality, by the
twenty-fifth (25th) of each month. For the purposes of verifying costs are allowable and equitable,
CONTRACTOR shall submit any additional documentation as deemed necessary by DBH.
B. COUNTY’s DBH shall invoice CONTRACTOR in arrears by the fifth (5th) day of
the month for the prior month’s hosting fee for access to COUNTY’s electronic information system in
accordance with the fee schedule set forth in Exhibit F, “Electronic Health Records Software Charges,”
attached hereto and incorporated herein by this reference and made part of this Agreement. COUNTY
shall invoice CONTRACTOR(S) annually for the annual maintenance and licensing fee for access to
COUNTY’s electronic information system in accordance with the fee schedule as set forth in Exhibit F.
CONTRACTOR shall provide payment for these expenditures to COUNTY’s Department of Behavioral
Health, Accounts Receivable, P.O. Box 712, Fresno, CA 93717-0712, Attention: Business Office, within
forty-five (45) days after the date of receipt by CONTRACTOR of the invoicing provided by COUNTY.
7. LICENSING-CERTIFICATES
Throughout each term of this Agreement, CONTRACTOR and CONTRACTOR’s staff shall
maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions necessary for the
provision of the services hereunder and required by the laws and regulations of the United States of
America, State of California, the County of Fresno, and any other applicable governmental agencies.
CONTRACTOR shall notify COUNTY immediately in writing of its inability to obtain or maintain such
licenses, permits, approvals, certificates, waivers and exemptions irrespective of the pendency of any
appeal related thereto. Additionally, CONTRACTOR and CONTRACTOR’s staff shall comply with all
applicable laws, rules or regulations, as may now exist or be hereafter changed.
8. RESIDENTIAL AOD CERTIFICATION
A. The COUNTY requires all COUNTY contractors of residential Alcohol and Other
Substance Use Disorder treatment services to obtain the California Department of Health Care Services
(DHCS) Alcohol and Other Drug Program (AOD) Certification, including the program’s American Society of
Addiction Medicine (ASAM) level of care designation.
B. Residential CONTRACTOR(S) shall provide proof of a completed application for
AOD Certification to the County within thirty (30) days from the execution date of this Agreement with the
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COUNTY. A copy of the AOD Certification shall be submitted to the COUNTY when approved by DHCS.
C. COUNTY shall terminate this Agreement immediately in the event any of the
following occurs:
1) CONTRACTOR fails to submit a copy of the completed application for AOD
Certification within thirty (30) days from the execution date of this Agreement with the COUNTY.
2) CONTRACTOR’s application for AOD Certification is denied by DHCS.
3) CONTRACTOR fails to submit to the COUNTY a copy of the AOD
Certification within thirty (30) days after being approved by the DHCS, or certification is not maintained
throughout the contract period.
9. PERINATAL SERVICES
CONTRACTOR shall comply with the requirements of the "Perinatal Practice Guidelines,"
available at the DHCS web address at: http://www.dhcs.ca.gov/individuals/Pages/Perinatal-
Services.aspx and by this reference incorporated herein, until such time new Perinatal Practice
Guidelines are updated and adopted. No formal amendment of this contract is required for new
guidelines to apply. Additionally, CONTRACTOR shall comply with the perinatal requirements stated in
Exhibit C, “Drug Medi-Cal Specific Requirements.” No formal amendment of this contract is required for
new guidelines or amendments to Exhibit C to apply.
CONTRACTOR shall comply with federal and state mandates to provide alcohol and
other drug treatment services deemed medically necessary for Medi-Cal eligible: (1) pregnant and
postpartum women, and (2) youth under age 21 who are eligible under the Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Program.
CONTRACTOR shall require that counselors of perinatal DMC services are properly
certified to provide these services and comply with the requirements contained in Title 22, § 51341.1,
Services for Pregnant and Postpartum Women and Title 9 commencing with section 10360.
10. PROHIBITION ON PUBLICITY
None of the funds, materials, property or services provided directly or indirectly under this
Agreement shall be used for CONTRACTOR’s advertising, fundraising, or publicity (i.e., purchasing of
tickets/tables, silent auction donations, etc.) for the purpose of self-promotion. Notwithstanding the above,
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publicity of the services described in Section One (1), SERVICES, of this Agreement shall be allowed as
necessary to raise public awareness about the availability of such specific services when approved in
advance by the DBH Director or her designee, and at a cost to be provided for such items as written/printed
materials, the use of media (i.e., radio, television, newspapers) and any other related expense(s).
11. NO THIRD PARTY BENEFICIARIES
It is understood and agreed by and between the parties that the services provided by
CONTRACTOR for COUNTY herein are solely for the benefit of the COUNTY, and that nothing in this
Agreement is intended to confer on any person other than the parties hereto any right under or by reason
of this Agreement.
12. INDEPENDENT CONTRACTOR
In performance of the work, duties and obligations assumed by CONTRACTOR under this
Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of the
CONTRACTOR'S officers, agents, and employees will at all times be acting and performing as an
independent contractor, and shall act in an independent capacity and not as an officer, agent, servant,
employee, joint venturer, partner, or associate of the COUNTY. Furthermore, COUNTY shall have no right
to control or supervise or direct the manner or method by which CONTRACTOR shall perform its work and
function. However, COUNTY shall retain the right to administer this Agreement so as to verify that
CONTRACTOR is performing its obligations in accordance with the terms and conditions thereof.
CONTRACTOR and COUNTY shall comply with all applicable provisions of law and the
rules and regulations, if any, of governmental authorities having jurisdiction over matters the subject
thereof.
Because of its status as an independent contractor, CONTRACTOR shall have absolutely
no right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall be
solely liable and responsible for providing to, or on behalf of, its employees all legally-required employee
benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY harmless from all
matters relating to payment of CONTRACTOR'S employees, including compliance with Social Security
withholding and all other regulations governing such matters. It is acknowledged that during the term of this
Agreement, CONTRACTOR may be providing services to others unrelated to the COUNTY or to this
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Agreement.
13. NON-ASSIGNMENT / SUBCONTRACTS
Neither party shall assign, transfer or sub-contract this Agreement nor their rights or duties
under this Agreement without the prior written consent of the other party.
CONTRACTOR shall be required to assume full responsibility for all services and activities
covered by this Agreement, whether or not CONTRACTOR is providing services directly. Further,
CONTRACTOR shall be the sole point of contact with regard to contractual matters, including payment of
any and all charges resulting from this Agreement.
If CONTRACTOR should propose to subcontract with one or more third parties to carry out
a portion of services covered by this Agreement, any such subcontract shall be in writing and approved as
to form and content by COUNTY’s DBH Director or her designee prior to execution and implementation.
COUNTY’s DBH Director or her designee shall have the right to reject any such proposed subcontract.
Any such subcontract together with all activities by or caused by CONTRACTOR shall not require
compensation greater than the total budget contained herein. An executed copy of any such subcontract
shall be received by COUNTY before any implementation and shall be retained by COUNTY.
CONTRACTOR shall be responsible to COUNTY for the proper performance of any subcontract. Any
subcontractor shall be subject to the same terms and conditions that CONTRACTOR is subject to under
this Agreement.
It is expressly recognized that CONTRACTOR cannot engage in the practice of physical
health medicine. If any medical services outside of the scope of the CONTRACTOR’s medical director are
provided in connection with the services under this Agreement, such medical services shall be performed
by an independent contract physician. In this instance, the requirements of the Confidential Medical
Information Act (Civil Code 56 et seq.) shall be met.
If CONTRACTOR hires an independent contract physician, CONTRACTOR shall require
and ensure that such independent contract physician carries Professional Liability (Medical Malpractice)
Insurance, with limits of not less than One Million Dollars ($1,000,000.00) per occurrence, Three Million
Dollars ($3,000,000.00) annual aggregate.
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14. CONFLICT OF INTEREST
No officer, agent, or employee of COUNTY who exercises any function or responsibility for
planning and carrying out the services provided under this Agreement shall have any direct or indirect
personal financial interest in this Agreement. CONTRACTOR shall comply with all Federal, State of
California, and local conflict of interest laws, statutes, and regulations, which shall be applicable to all
parties and beneficiaries under this Agreement and any officer, agent, or employee of COUNTY.
15. DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a
for-profit or non-profit corporation) or if during the term of the agreement, the CONTRACTOR changes
its status to operate as a corporation.
Members of the CONTRACTOR’s Board of Directors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR is providing goods or performing services
under this agreement. A self-dealing transaction shall mean a transaction to which the CONTRACTOR
is a party and in which one or more of its directors has a material financial interest. Members of the
Board of Directors shall disclose any self-dealing transactions that they are a party to by completing and
signing a Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit G and incorporated
herein by reference, and submitting it to the COUNTY prior to commencing with the self-dealing
transaction or immediately thereafter.
16. ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that it is not currently excluded,
suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; that it has
not been convicted of a criminal offense related to the provision of health care items or services; nor has it
been reinstated to participation in the Federal Health Care Programs after a period of exclusion,
suspension, debarment, or ineligibility. If COUNTY learns, subsequent to entering into a contract, that
CONTRACTOR is ineligible on these grounds, COUNTY will remove CONTRACTOR from responsibility
for, or involvement with, COUNTY’s business operations related to the Federal Health Care Programs and
shall remove such CONTRACTOR from any position in which CONTRACTOR’s compensation, or the
items or services rendered, ordered or prescribed by CONTRACTOR may be paid in whole or part, directly
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or indirectly, by Federal Health Care Programs or otherwise with Federal Funds at least until such time as
CONTRACTOR is reinstated into participation in the Federal Health Care Programs. Further the
CONTRACTOR agrees to the Disclosure of Criminal History and Civil Actions and Certification regarding
debarment suspension and other responsibility matters primary covered transactions; CONTRACTOR
must sign an appropriate Certification regarding debarment, suspension, and other responsibility matters,
attached hereto as Exhibit H, incorporated herein by reference and made part of this Agreement.
A. If COUNTY has notice that CONTRACTOR has been charged with a criminal
offense related to any Federal Health Care Program, or is proposed for exclusion during the term on any
contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the accuracy of any
claims submitted to any Federal Health Care Program. At its discretion given such circumstances,
COUNTY may request that CONTRACTOR cease providing services until resolution of the charges or the
proposed exclusion.
B. CONTRACTOR agrees that all potential new employees of CONTRACTOR or
subcontractors of CONTRACTOR who, in each case, are expected to perform professional services under
this Agreement, will be queried as to whether (1) they are now or ever have been excluded, suspended,
debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2) they have been
convicted of a criminal offense related to the provision of health care items or services; and or (3) they
have been reinstated to participation in the Federal Health Care Programs after a period of exclusion,
suspension, debarment, or ineligibility.
1) In the event the potential employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR hires
or engages such potential employee or subcontractor, CONTRACTOR will ensure that said employee or
subcontractor does no work, either directly or indirectly relating to services provided to COUNTY.
2) Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section Four (4) TERMINATION of this Agreement, or require adequate
assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or
subcontractor of CONTRACTOR will perform work, either directly or indirectly, relating to services
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provided to COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be
determined by COUNTY to protect the interests of COUNTY beneficiaries.
C. CONTRACTOR shall verify (by asking the applicable employees and
subcontractors) that all current employees and existing subcontractors who, in each case, are expected to
perform professional services under this Agreement (1) are not currently excluded, suspended, debarred,
or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been convicted of a
criminal offense related to the provision of health care items or services; and (3) have not been reinstated
to participation in the Federal Health Care Program after a period of exclusion, suspension, debarment, or
ineligibility. In the event any existing employee or subcontractor informs CONTRACTOR that he or she is
excluded, suspended, debarred or otherwise ineligible to participate in the Federal Health Care Programs,
or has been convicted of a criminal offense relating to the provision of health care services,
CONTRACTOR will ensure that said employee or subcontractor does no work, either direct or indirect,
relating to services provided to COUNTY.
1) CONTRACTOR agrees to notify COUNTY immediately during the term of
this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each case, is
providing professional services under this Agreement is excluded, suspended, debarred or otherwise
ineligible to participate in the Federal Health Care Programs, or is convicted of a criminal offense relating
to the provision of health care services.
2) Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with the Section Four (4) TERMINATION of this Agreement, or require
adequate assurance (as defined by COUNTY) that no excluded, suspended or otherwise ineligible
employee or subcontractor of CONTRACTOR will perform work, either directly or indirectly, relating to
services provided to COUNTY. Such demand for adequate assurance shall be effective upon a time
frame to be determined by COUNTY to protect the interests of COUNTY beneficiaries.
D. CONTRACTOR agrees to cooperate fully with any reasonable requests for
information from COUNTY which may be necessary to complete any internal or external audits relating to
this Agreement.
E. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
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imposed upon COUNTY by the Federal Government as a result of CONTRACTOR’s violation of the terms
of this Agreement.
17. MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent of
all the parties without, in any way, affecting the remainder.
Notwithstanding the above, changes to Section One (1), SERVICES, as needed to
accommodate changes in State and Federal Law relating to SUD treatment may be made with the signed
written approval of COUNTY’s DBH Director or her designee and respective CONTRACTOR(S) through an
amendment approved by County Counsel and Auditor.
18. INSURANCE
Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR or any
third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect, the following
insurance policies or a program of self-insurance, including but not limited to, an insurance pooling
arrangement or Joint Powers Agreement (JPA) throughout the term of the Agreement:
A. Commercial General Liability
Commercial General Liability Insurance with limits of not less than Two Million
Dollars ($2,000,000.00) per occurrence and an annual aggregate of Four Million Dollars ($4,000,000.00).
This policy shall be issued on a per occurrence basis. COUNTY may require specific coverages including
completed operations, products liability, contractual liability, Explosion-Collapse-Underground, fire legal
liability or any other liability insurance deemed necessary because of the nature of this contract.
B. Automobile Liability
Comprehensive Automobile Liability Insurance with limits of not less than One
Million Dollars ($1,000,000.00) per accident for bodily injury and for property damages. Coverage should
include any auto used in connection with this Agreement.
C. Professional Liability
If CONTRACTOR employs licensed professional staff, (e.g., Ph.D., R.N., L.C.S.W.,
M.F.C.C.) in providing services, Professional Liability Insurance with limits of not less than One Million
Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) annual aggregate.
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D. Worker's Compensation
A policy of Worker's Compensation insurance as may be required by the California
Labor Code.
E. Molestation
Sexual abuse / molestation liability insurance with limits of not less than One Million Dollars
($1,000,000.00) per occurrence, Two Million Dollars ($2,000,000.00) annual aggregate. This policy shall be
issued on a per occurrence basis.
CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance
naming the County of Fresno, its officers, agents, and employees, individually and collectively, as additional
insured, but only insofar as the operations under this Agreement are concerned. Such coverage for
additional insured shall apply as primary insurance and any other insurance, or self-insurance, maintained
by COUNTY, its officers, agents and employees shall be excess only and not contributing with insurance
provided under CONTRACTOR's policies herein. This insurance shall not be cancelled or changed without
a minimum of thirty (30) days advance written notice given to COUNTY.
CONTRACTOR hereby waives its right to recover from COUNTY, its officers, agents, and
employees any amounts paid by the policy of worker’s compensation insurance required by this
Agreement. CONTRACTOR is solely responsible to obtain any endorsement to such policy that may be
necessary to accomplish such waiver of subrogation, but CONTRACTOR’s waiver of subrogation under
this paragraph is effective whether or not CONTRACTOR obtains such an endorsement.
Within thirty (30) days from the date CONTRACTOR signs and executes this Agreement,
CONTRACTOR shall provide certificates of insurance and endorsement as stated above for all of the
foregoing policies, as required herein, to the assigned analyst at the County of Fresno, Department of
Behavioral Health, Contracts Division – SUD Services at 3133 N Millbrook Avenue, Fresno, California,
93703, stating that such insurance coverages have been obtained and are in full force; that the County of
Fresno, its officers, agents and employees will not be responsible for any premiums on the policies; that for
such worker’s compensation insurance the CONTRACTOR has waived its right to recover from the
COUNTY, its officers, agents, and employees any amounts paid under the insurance policy and that waiver
does not invalidate the insurance policy; that such Commercial General Liability insurance names the
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County of Fresno, its officers, agents and employees, individually and collectively, as additional insured, but
only insofar as the operations under this Agreement are concerned; that such coverage for additional
insured shall apply as primary insurance and any other insurance, or self-insurance, maintained by
COUNTY, its officers, agents and employees, shall be excess only and not contributing with insurance
provided under CONTRACTOR's policies herein; and that this insurance shall not be cancelled or changed
without a minimum of thirty (30) days advance, written notice given to COUNTY.
In the event CONTRACTOR fails to keep in effect at all times insurance coverage as herein
provided, the COUNTY may, in addition to other remedies it may have, suspend or terminate this
Agreement upon the occurrence of such event.
All policies shall be issued by admitted insurers licensed to do business in the State of
California, and such insurance shall be purchased from companies possessing a current A.M. Best, Inc.
rating of A FSC VII or better.
19. HOLD HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY'S request,
defend the COUNTY, its officers, agents, and employees from any and all costs and expenses (including
attorney’s fees and costs), damages, liabilities, claims, and losses occurring or resulting to COUNTY in
connection with the performance, or failure to perform, by CONTRACTOR, its officers, agents, or
employees under this Agreement, and from any and all costs and expenses (including attorney’s fees and
costs), damages, liabilities, claims, and losses occurring or resulting to any person, firm, or corporation who
may be injured or damaged by the performance, or failure to perform, of CONTRACTOR, its officers,
agents, or employees under this Agreement.
CONTRACTOR agrees to indemnify COUNTY for Federal, State of California audit
exceptions resulting from noncompliance herein on the part of the CONTRACTOR.
20. SINGLE AUDIT
A. If CONTRACTOR expends Seven Hundred Fifty Thousand Dollars ($750,000.00) or
more in Federal and Federal flow-through monies, CONTRACTOR agrees to conduct an annual audit in
accordance with the requirements of the Single Audit Standards as set forth in 2 Code of Federal
Regulations (CFR) Part 200. CONTRACTOR shall submit said audit and management letter to COUNTY.
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The audit must include a statement of findings or a statement that there were no findings. If there were
negative findings, CONTRACTOR must include a corrective action plan signed by an authorized
individual. CONTRACTOR agrees to take action to correct any material non-compliance or weakness
found as a result of such audit. Such audit shall be delivered to COUNTY’s Department of Behavioral
Health, Business Office for review within nine (9) months of the end of any fiscal year in which funds were
expended and/or received for the program. Failure to perform the requisite audit functions as required by
this Agreement may result in COUNTY performing the necessary audit tasks, or at COUNTY’s option,
contracting with a public accountant to perform said audit, or, may result in the inability of COUNTY to
enter into future agreements with CONTRACTOR. All audit costs related to this Agreement are the sole
responsibility of CONTRACTOR.
B. A single audit report is not applicable if CONTRACTOR’s Federal contracts do not
exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or CONTRACTOR’s only
funding is through Drug related Medi-Cal. If a single audit is not applicable, a program audit must be
performed and a program audit report with management letter shall be submitted by CONTRACTOR to
COUNTY as a minimum requirement to attest to CONTRACTOR’s solvency. Said audit report shall be
delivered to COUNTY’s Department of Behavioral Health, Business Office for review, no later than nine (9)
months after the close of the fiscal year in which the funds supplied through this Agreement are expended.
Failure to comply with this Act may result in COUNTY performing the necessary audit tasks or contracting
with a qualified accountant to perform said audit. All audit costs related to this Agreement are the sole
responsibility of CONTRACTOR who agrees to take corrective action to eliminate any material
noncompliance or weakness found as a result of such audit. Audit work performed by COUNTY under this
section shall be billed to the CONTRACTOR at COUNTY’s cost, as determined by COUNTY’s Auditor-
Controller/Treasurer-Tax Collector.
C. CONTRACTOR shall make available all records and accounts for inspection by
COUNTY, the State of California, if applicable, the Comptroller General of the United States, the Federal
Grantor Agency, or any of their duly authorized representatives, at all reasonable times for a minimum of
ten (10) years, in accordance with 42 CFR Part 438.3(h), from the finalized cost settlement process or, if an
audit by the Federal government or DHCS has been started before the expiration of the ten (10) year
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period, records shall be maintained until completion of the audit and final resolution of all findings.
21. AUDITS AND INSPECTIONS
The CONTRACTOR shall at any time during business hours, and as often as the COUNTY
may deem necessary, make available to the COUNTY for examination all of its records and data with
respect to the matters covered by this Agreement. The CONTRACTOR shall, upon request by the
COUNTY, permit the COUNTY to audit and inspect all electronic or print books and records as well as
inspection of the premises, physical facilities and equipment where Medicaid-related activities are
conducted to ensure CONTRACTOR'S compliance with the terms of this Agreement.
The refusal of CONTRACTOR to permit access to, and inspection of, electronic or print
books and records, physical facilities, and/or refusal to permit interviews with employees, as described in
this part, constitutes an express and immediate material breach of this Agreement and will be sufficient
basis to terminate the Agreement for cause or default.
The right to audit under this section exists for ten (10) years from the final date of the
agreement period or from the date of completion of any audit, whichever is later.
Notwithstanding the provisions stated in Section Three (3), TERM, of this Agreement, it is
acknowledged by the parties hereto that this Agreement shall continue in full force and effect until all audit
procedures and requirements as stated in this Agreement have been completed to the review and
satisfaction of COUNTY. CONTRACTOR shall bear all costs in connection with or resulting from any audit
and/or inspections including, but not limited to, actual costs incurred and the payment of any expenditures
disallowed by either COUNTY, State, or Federal governmental entities, including any assessed interest and
penalties.
If CONTRACTOR, through an audit by the STATE or COUNTY, is found to be in violation of
this contract which results in the recoupment of funds paid to CONTRACTOR, COUNTY may, upon mutual
consent between CONTRACTOR and COUNTY, enter into a repayment agreement with the
CONTRACTOR, with total monthly payments not to exceed twelve (12) months from the date of the
repayment agreement, to recover the amount of funds to be recouped. The monthly repayment amounts
shall be netted against the CONTRACTOR’s monthly billing for services rendered during the month.
COUNTY reserves the right to forgo a repayment agreement and recoup all funds immediately.
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22. EVALUATION – MONITORING
CONTRACTOR shall participate in a review of the program at least yearly or more
frequently, or as needed, at the discretion of COUNTY. The CONTRACTOR agrees to supply all
information requested by the COUNTY, DHCS, and/or the subcontractor during the program evaluation,
monitoring, and/or review.
COUNTY’s DBH Director, or her designee, and DHCS or their designees shall monitor and
evaluate the performance of CONTRACTOR under this Agreement to determine to the best possible
degree the success or failure of the services provided under this Agreement. At the discretion of the
COUNTY, a subcontractor may be obtained by the COUNTY to independently evaluate and monitor the
performance of the CONTRACTOR. CONTRACTOR shall participate in the evaluation of the program as
needed, at the discretion of COUNTY.
COUNTY shall recapture from CONTRACTOR the value of any services or other
expenditures determined to be ineligible based on the COUNTY or State monitoring results. At the
discretion of the COUNTY, CONTRACTOR shall enter into a repayment agreement with the COUNTY, with
total monthly payments not to exceed twelve (12) months from the date of the repayment agreement, to
recover the amount of funds to be recouped. The monthly repayment amounts shall be netted against the
CONTRACTOR’s monthly billing for services rendered during the month. COUNTY reserves the right to
forgo a repayment agreement and recoup all funds immediately.
23. REPORTS—SUBSTANCE USE DISORDER SERVICES
CONTRACTOR(S) shall submit all information and data required by State, including, but
not limited to the following:
A. Drug and Alcohol Treatment Access Report (DATAR) in an electronic format
provided by the State and due no later than five (5) days after the preceding month; and
B. CalOMS Treatment – Submit CalOMS treatment admission, discharge, annual
update, and “provider activity report” record in an electronic format through COUNTY’s information
system, and on a schedule as determined by the COUNTY which complies with State requirements for
data content, data quality, reporting frequency, reporting deadlines, and report method and due no later
than five (5) days after the preceding month. All CalOMS admissions, discharges, and annual updates
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must be entered into the COUNTY’s CalOMS system within twenty-four (24) hours of occurrence; and
C. CONTRACTOR(S) shall submit to COUNTY monthly fiscal and all program
reports, including DMC Monthly Status Report (MSR), within twenty (20) days of the end of each month;
and
D. ASAM Level of Care (LOC) – Submit ASAM LOC data in an electronic format
through COUNTY’s information system, on a schedule as determined by the COUNTY which complies
with State requirements; and
E. Americans with Disabilities (ADA) – Annually, upon request by DBH,
CONTRACTOR(S) shall complete a system-wide accessibility survey in a format determined by DBH for
each service location and modality and shall submit an ADA Accessibility Certification and Self-
Assessment, including an Implementation Plan, for each service location; and
F. Culturally and Linguistically Appropriate Services (CLAS) - Annually, upon request
by DBH, CONTRACTOR(S) shall complete an agency CLAS survey in a format determined by DBH and
shall submit a CLAS Self-Assessment, including an Implementation Plan; and
G. Risk Assessment – Annually, upon request by DBH, CONTRACTOR shall submit
a Risk Assessment on a form and in a format to be provided by DBH. The Assessment must be
submitted to the COUNTY in hard copy as well as electronically by the due date set by COUNTY; and
H. Outcome Reports – CONTRACTOR shall submit outcomes reports as requested.
Outcomes reports and requirements are subject to change at COUNTY’s discretion; and
I. Network Adequacy Certification Tool (NACT) – CONTRACTOR shall submit
NACT as requested by COUNTY; and
J. Cost Reports – On an annual basis for each fiscal year ending June 30th
CONTRACTOR(S) shall submit a complete and accurate detailed cost report(s). Cost reports must be
submitted to the COUNTY as a hard copy with a signed cover letter and an electronic copy by the due
date. Submittal must also include any requested support documents such as general ledgers and
detailed electronic (e.g. Excel) schedules demonstrating how costs were allocated both within programs,
if provider has multiple funding sources (e.g. DMC and SAPT), and between programs, if
CONTRACTOR provides multiple SUD modalities (e.g. residential, detox, sober living, outpatient, etc.).
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Provider shall maintain general ledgers that reflect the original transaction amounts where each entry in
their accounting records represents one-hundred percent (100%) of the total transaction cost and can
be supported with the original source documentation (i.e. receipts, bills, invoices, payroll registers, etc.).
Bank statements reflecting purchases are not original source documents and will not be accepted as
such. All costs found to not be supported by original source documentation will be disallowed. Total
unallowable costs shall be allocated their percentage share of the indirect Costs along with the
Contractor’s direct costs. All reports submitted by CONTRACTOR(S) to COUNTY must be typewritten.
COUNTY will issue instructions for completion and submittal of the annual cost report, including the
relevant cost report template(s) and due dates within forty-five (45) days of each fiscal year end. All cost
reports must be prepared in accordance with Generally Accepted Accounting Principles. Unallowable
costs such as those denoted in 2 CFR 200 Subpart E, Cost Principles, 41 U.S.C. 4304, and the Center
for Medicare and Medicaid Studies (CMS) Provider Reimbursement Manual (PRM) 15-1, must not be
included as an allowable cost on the cost report and all invoices. Unallowable costs must be kept in the
provider’s General Ledger in accounts entitled Unallowable followed by name of the account (e.g.
Unallowable – Food) or in some other appropriate form of segregation in the provider’s accounting
records. For further information on unallowable costs refer to regulations provided above. If the
CONTRACTOR(S) does not submit the cost report by the due date, including any extension period
granted by the COUNTY, the COUNTY may withhold payment of pending invoices until the cost
report(s) has been submitted and clears COUNTY desk audit for completeness and accuracy. Once the
cost reports have been approved by the County, originally-executed signed certification pages attesting
to the accuracy of the information contained in cost reports shall be submitted to the County.
1) DMC - A DMC cost report must be submitted in a format prescribed by the
DHCS for the purposes of Short Doyle Medi-Cal reimbursement of total costs for all programs.
CONTRACTOR(S) shall report costs under their approved legal entity number established during the
DMC certification process. Total units of service reported on the cost report will be compared to the
units of services entered by CONTRACTOR(S) into COUNTY’s data system. CONTRACTOR(S) will be
required to correct discrepancies and resubmit to COUNTY prior to COUNTY’s final acceptance of the
cost report.
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2) OTHER FUNDING SOURCES – CONTRACTOR(S) will be required to
submit a cost report on a form approved and provided by the COUNTY to reflect actual costs and
reimbursement for services provided through funding sources other than DMC. Contracts that include a
negotiated rate per unit of service will be reimbursed for actual costs incurred (the sum of both direct
costs as defined in 2 CFR 200.413, and allocated indirect costs as defined in 2 CFR 200.414) not to
exceed the contract maximum. If the cost report indicates an amount due to COUNTY,
CONTRACTOR(S) shall submit payment with the report. If an amount is due to CONTRACTOR(S)
COUNTY shall reimburse CONTRACTOR within forty-five (45) days of receiving and accepting the year-
end cost report.
3) MULTIPLE FUNDING SOURCES – CONTRACTOR(S) with multiple
agreements for the same services (e.g. Outpatient, Residential) provided at the same location where at
least one of the Agreements is funded through DMC and the other funding is other federal or county
realignment funding will be required to complete DMC cost reports and COUNTY approved cost reports.
Such Agreements will be settled for actual allowable costs in accordance with Medicaid reimbursement
requirements as specified in Title XIX or Title XXI of the Social Security Act; Title 22, and the State’s
Medicaid Plan. Within forty-five (45) days of the reconciliation by COUNTY, CONTRACTOR shall make
payment to COUNTY or COUNTY shall reimburse CONTRACTOR as appropriate.
During the term of this Agreement and thereafter, COUNTY and CONTRACTOR(S)
agree to settle dollar amounts disallowed or settled in accordance with DHCS and COUNTY audit
settlement findings. DHCS audit process is approximately eighteen (18) to thirty-six (36) months
following the close of the State fiscal year. COUNTY may choose to appeal DHCS settlement results
and therefore reserves the right to defer payback settlement with CONTRACTOR(S) until resolution of
the appeal.
CONTRACTOR shall furnish to COUNTY such statements, records, reports, data, and
information as COUNTY may request pertaining to matters covered by this Agreement. All reports
submitted to the COUNTY must be typewritten.
In the event that CONTRACTOR(S) fails to provide such reports or other information
required hereunder, it shall be deemed sufficient cause for the COUNTY to withhold monthly payments
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until there is compliance. In addition, the CONTRACTOR shall provide written notification and
explanation to the COUNTY within fifteen (15) days of any funds received from another source to
conduct the same services covered by this Agreement.
24. PROPERTY OF COUNTY
A. CONTRACTOR shall submit purchase invoices for the purchase of any fixed assets
with their monthly invoices. All purchases over Five Thousand and No/100 Dollars ($5,000.00), and certain
purchases under Five Thousand and No/100 Dollars ($5,000.00) such as fans, calculators, cameras,
VCRs, DVDs and other sensitive items as determined by COUNTY’s DBH Director, or her designee, made
during the life of this Agreement shall be identified as assets that can be inventoried and maintained in
COUNTY’s DBH Asset Inventory System. These assets shall be retained by COUNTY, as COUNTY
property, in the event this Agreement is terminated or upon expiration of this Agreement. CONTRACTOR
agrees to participate in an annual inventory of all COUNTY fixed assets and shall be physically present
when fixed assets are returned to COUNTY’s possession at the termination or expiration of this Agreement.
CONTRACTOR is responsible for returning to COUNTY all COUNTY owned fixed assets, or the monetary
value of said fixed assets if unable to produce the fixed assets at the expiration or termination of this
Agreement.
B. The purchase of any equipment by CONTRACTOR with funds provided
hereunder shall require the prior written approval of COUNTY’s DBH Director or her designee, shall
fulfill the provisions of this Agreement as appropriate, and must be directly related to CONTRACTOR’s
services or activity under the terms of this Agreement. COUNTY’s DBH Director or her designee may
refuse reimbursement for any costs resulting from equipment purchased, which are incurred by
CONTRACTOR, if prior written approval has not been obtained from COUNTY.
C. The terms and conditions described in this Section are not applicable to the
leasing of vehicles by CONTRACTOR with the funds provided under this Agreement.
25. RECORDS
A. RECORD ESTABLISHMENT AND MAINTENANCE –CONTRACTOR shall
establish and maintain records in accordance with State and Federal rules and regulations in addition to
those requirements prescribed by COUNTY with respect to all matters covered by this Agreement.
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Except as otherwise authorized by COUNTY, CONTRACTOR shall retain all other records for a period
of ten (10) years from the finalized cost settlement process, or from the date of completion of any audit,
whichever is later.
B. DOCUMENTATION – CONTRACTOR shall maintain adequate records in
sufficient detail to make possible an evaluation of services, and contain all the data necessary in
reporting to the State of California and/or Federal agency. All client records shall be maintained
pursuant to applicable State of California and Federal requirements concerning confidentiality.
C. REPORTS – CONTRACTOR shall submit to COUNTY monthly fiscal and all
program reports as further described in Section Twenty-Three (23) REPORTS – Substance Use
Disorder Services. CONTRACTOR shall submit a complete and accurate year-end cost report for each
fiscal year affected by this Agreement, following the end of each fiscal year affected by this Agreement.
CONTRACTOR shall also furnish to COUNTY such statements, records, reports, data, and information
as COUNTY may request pertaining to matters covered by this Agreement. All reports submitted by
CONTRACTOR to COUNTY must be typewritten.
D. SUSPENSION OF COMPENSATION – In the event that CONTRACTOR fails to
provide reports specified in this Agreement, it shall be deemed sufficient cause for COUNTY to withhold
payments until there is compliance.
E. CLIENT CONFIDENTIALITY – CONTRACTOR shall conform to and COUNTY
shall monitor compliance with all State and Federal statutes and regulations regarding confidentiality,
including but not limited to confidentiality of information requirements of 42 CFR § 2.1 et seq., Welfare
and Institutions Code §§ 5328, 10850 and 14100.2, Health and Safety Code §§ 11977 and 11812, Civil
Code, Division 1, Part 2.6, and CCR Title 22 § 51009.
26. DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access,
viewing, use or disclosure of COUNTY data including sensitive or personal beneficiary information; abuse
of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that enter
into a contractual relationship with the COUNTY for the purpose of providing services under this Agreement
must employ adequate data security measures to protect the confidential information provided to
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CONTRACTOR by the COUNTY, including but not limited to the following:
A. CONTRACTOR-OWNED MOBILE, WIRELESS, OR HANDHELD DEVICES
CONTRACTOR may not connect to COUNTY networks via personally-owned
mobile, wireless or handheld devices, unless the following conditions are met:
1) CONTRACTOR has received authorization by COUNTY for telecommuting
purposes;
2) Current virus protection software is in place;
3) Mobile device has the remote wipe feature enabled; and
4) A secure connection is used.
B. CONTRACTOR-OWNED COMPUTERS OR COMPUTER PERIPHERALS
CONTRACTOR may not bring CONTRACTOR-owned computers or computer
peripherals into the COUNTY for use without prior authorization from the COUNTY’s Chief Information
Officer, and/or designee(s), including but not limited to mobile storage devices. If data is approved to be
transferred, data must be stored on a secure server approved by the COUNTY and transferred by means
of a Virtual Private Network (VPN) connection, or another type of secure connection. Said data must be
encrypted.
C. COUNTY-OWNED COMPUTER EQUIPMENT
CONTRACTOR or anyone having an employment relationship with the COUNTY
may not use COUNTY computers or computer peripherals on non-COUNTY premises without prior
authorization from the COUNTY’s Chief Information Officer, and/or designee(s).
D. CONTRACTOR may not store COUNTY’s private, confidential or sensitive data on
any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
E. CONTRACTOR shall be responsible to employ strict controls to ensure the integrity
and security of COUNTY’s confidential information and to prevent unauthorized access, viewing, use or
disclosure of data maintained in computer files, program documentation, data processing systems, data
files and data processing equipment which stores or processes COUNTY data internally and externally.
F. Confidential beneficiary information transmitted to one party by the other by means
of electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of 128
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BIT or higher. Additionally, a password or pass phrase must be utilized.
G. CONTRACTOR is responsible to immediately notify COUNTY of any violations,
breaches or potential breaches of security related to COUNTY’s confidential information, data maintained
in computer files, program documentation, data processing systems, data files and data processing
equipment which stores or processes COUNTY data internally or externally.
H. COUNTY shall provide oversight to CONTRACTOR’s response to all incidents
arising from a possible breach of security related to COUNTY’s confidential beneficiary information
provided to CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected
individuals as required by law or as deemed necessary by COUNTY in its sole discretion. CONTRACTOR
will be responsible for all costs incurred as a result of providing the required notification.
27. EHR CERTIFICATION
CONTRACTOR shall obtain certification from the Certification Commission for Healthcare
Information Technology (CCHIT) for Security Access Control, Audit, and Authentication if using a non-
Avatar electronic health record (EHR) and shall provide a copy of the certification to COUNTY. Additionally,
CONTRACTOR shall recertify their EHR annually and provide a copy of the recertification to COUNTY.
CONTRACTOR shall ensure all employees who use an EHR other than Avatar sign an Electronic
Signature Agreement (See example, Exhibit I) and maintain a copy in the employee’s personnel file.
28. COMPLIANCE WITH LAWS, POLICIES AND RULES
CONTRACTOR shall comply with all applicable rules and regulations set forth in CCR Titles
9 and 22, and California Health and Safety Code § 11750 et seq., with the exception of regulations waived
by the Centers for Medicare and Medicaid Services and DHCS, as stated within the DMC-Organized
Delivery Service Special Terms and Conditions and the DMC Intergovernmental Agreement.
CONTRACTOR shall comply with any other Federal and State laws or guidelines applicable to
CONTRACTOR’s performance under this Agreement or any local ordinances, regulations, or policies
applicable. Such provisions include, but are not restricted to:
A. CONTRACTOR shall comply with 42 CFR Part 438.
B. CONTRACTOR shall comply with Early and Periodic Screening, Diagnostic and
Treatment (EPSDT) statutes and regulations.
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C. CONTRACTOR shall ensure that each beneficiary’s ability to pay for services is
determined by the use of the method approved by COUNTY.
D. CONTRACTOR shall establish and use COUNTY’s approved method of
determining and collecting fees from beneficiaries.
E. CONTRACTOR shall furnish beneficiary records in accordance with the applicable
Federal, State and local regulations and requirements, including in such records a treatment plan for each
beneficiary, and evidence of each service rendered.
F. CONTRACTOR shall submit accurate, complete and timely claims and cost reports,
reporting only allowable costs.
G. CONTRACTOR shall comply with statistical reporting and program evaluation
systems as provided in State of California regulations and in this Agreement.
H. CONTRACTOR shall comply with requirements contained in the Intergovernmental
Agreement with DHCS by this reference incorporated herein, until such time that a new Intergovernmental
Agreement is established. Upon amendment of the Intergovernmental Agreement, the terms of the
amended Contract shall automatically be incorporated into this Agreement.
I. CONTRACTOR shall inform every beneficiary of their rights regarding Grievance
and Appeals as described in the Provider Manual, attached hereto and by this reference incorporated.
J. CONTRACTOR shall file an incident report for all incidents involving beneficiaries,
following the Protocol for Completion of Incident Report described in the Provider Manual, attached hereto
and by this reference incorporated..
K. In the event any law, regulation, or policy referred to in this Agreement is amended
during the term thereof, the parties hereto agree to comply with the amended provision as of the effective
date of such amendment. Exhibits will be updated as needed and no formal amendment of this contract is
required for new rules to apply.
29. NON-DISCRIMINATION PROVISION
ELIGIBILITY FOR SERVICES – CONTRACTOR shall prepare, prominently post in its
facility, and make available to the DBH Director or her designee and to the public all eligibility
requirements to participate in the program funded under this Agreement. CONTRACTOR shall not
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unlawfully discriminate in the provision of services because of race, religious creed, color, national
origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital
status, sex, gender, gender identity, gender expression, age, sexual orientation, or military or veteran
status as provided by State of California and Federal law in accordance with Title VI of the Civil Rights
Act of 1964 (42 USC § 2000(d)); Age Discrimination Act of 1975 (42 USC § 1681); Rehabilitation Act of
1973 (29 USC § 794); Education Amendments of 1972 (20 USC § 1681); Americans with Disabilities Act
of 1990 (42 USC § 12132); 45 CFR, Part 84; provisions of the Fair Employment and Housing Act
(California Government Code § 12900); and regulations promulgated thereunder (CCR Title 2, §
7285.0); Title 2, Division 3, Article 9.5 of the California Government Code commencing with section
11135; and CCR Title 9, Division 4, Chapter 6 commencing with section 10800.
A. EQUAL OPPORTUNITY – CONTRACTOR shall comply with California Government
Code, § 2990 and CCR Title 2, Division 4, Chapter 5, in matters related to the development,
implementation, and maintenance of a nondiscrimination program. CONTRACTOR shall not discriminate
against any employee or applicant for employment because race, religious creed, color, national origin,
ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex,
gender, gender identity, gender expression, age, sexual orientation, or military or veteran status. 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. CONTRACTOR agrees to post in conspicuous places, notices available to all employees and
applicants for employment setting forth the provisions of the Equal Opportunity Act (42 USC § 2000(e)) in
conformance with Federal Executive Order No. 11246. CONTRACTOR agrees to comply with the
provisions of the Rehabilitation Act of 1973 (29 USC § 794).
B. SUSPENSION OF COMPENSATION – If an allegation of discrimination occurs,
DBH may withhold all further funds, until CONTRACTOR can show by clear and convincing evidence to the
satisfaction of DBH that funds provided under this Agreement were not used in connection with the alleged
discrimination.
C. NEPOTISM – Except by consent of the DBH Director or her designee, no person
shall be employed by CONTRACTOR who is related by blood or marriage to or who is a member of the
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Board of Directors or an officer of CONTRACTOR.
D. NEW FACILITIES AND DISABILITY ACCESS – New facilities shall be wheelchair
accessible and provide access to the disabled, consistent with CCR Title 9, § 10820. If a new facility will be
utilized, a plan ensuring accessibility to the disabled must be developed. DBH shall assess, monitor, and
document CONTRACTOR’s compliance with the Rehabilitation Act of 1973 and Americans with Disabilities
Act of 1990 to ensure that recipients/beneficiaries and intended recipients/beneficiaries of services are
provided services without regard to physical or mental disability and that CONTRACTOR has provided a
facility accessible to the physically disabled.
30. COMPLIANCE
CONTRACTOR(S) shall comply with all requirements of the “Fresno County Behavioral
Health Compliance Program Contractor Code of Conduct and Ethics” as set forth in Exhibit J. Within
thirty (30) days of entering into this Agreement with the COUNTY, CONTRACTOR(S) shall have all of
CONTRACTOR(S) employees, agents and subcontractors providing services under this Agreement
certify in writing, that they have received, read, understood, and shall abide by the requirements set
forth in Exhibit J. CONTRACTOR(S) shall ensure that within thirty (30) days of hire, all new employees,
agents and subcontractors providing services under this Agreement certify in writing that they have
received, read, understood, and shall abide by the requirements set forth in Exhibit J.
CONTRACTOR(S) understands that the promotion of and adherence to such requirements is an
element in evaluating the performance of CONTRACTOR(S) and its employees, agents and
subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees, agents and subcontractors providing services under this Agreement shall complete general
compliance training and appropriate employees, agents and subcontractors shall complete
documentation and billing or billing/reimbursement training. All new employees, agents and
subcontractors shall attend the appropriate training within thirty (30) days of hire. Each individual who is
required to attend training shall certify in writing that he or she has received the required training. The
certification shall specify the type of training received and the date received. The certification shall be
provided to the COUNTY’s Compliance Officer at 3133 N. Millbrook, Room 171, Fresno, CA 93703.
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CONTRACTOR(S) agrees to reimburse COUNTY for the entire cost of any penalty imposed upon
COUNTY by the Federal Government as a result of CONTRACTOR(S) violation of the terms of this
Agreement.
31.COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a beneficiary
or a beneficiary's family. CONTRACTOR shall provide a summary of the complaint log entries concerning
COUNTY-sponsored beneficiaries to COUNTY at monthly intervals by the fifteenth (15th) day of the
following month, in a format that is mutually agreed upon. CONTRACTOR shall post signs informing
beneficiary of their right to file a complaint or grievance. CONTRACTOR shall notify COUNTY of all
incidents reportable to state licensing bodies that affect COUNTY beneficiaries within twenty-four (24)
hours of receipt of a complaint.
Within fifteen (15) days after each incident or complaint affecting COUNTY-sponsored
beneficiaries, CONTRACTOR shall provide COUNTY with information relevant to the complaint,
investigative details of the complaint, the complaint and CONTRACTOR's disposition of, or corrective
action taken to resolve the complaint.
32.CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, CONTRACTOR shall comply with:
A.Compliance with Title 6 of the Civil Rights Act of 1964 (42 U.S.C. § 2000d, and
45 CFR Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance
from discriminating against persons based on race, color, national origin, sex, disability or religion. This is
interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access and
participation in federally funded programs through the provision of comprehensive and quality bilingual
services.
B.Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP beneficiaries, including, but not limited to,
assessing the cultural and linguistic needs of its beneficiaries, training of staff on the policies and
procedures, and monitoring its language assistance program. The CONTRACTOR’s procedures must
include ensuring compliance of any sub-contracted providers with these requirements.
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C. CONTRACTOR assurances that minors shall not be used as interpreters.
D. CONTRACTOR shall provide and pay for interpreting and translation services to
persons participating in CONTRACTOR’s services who have limited or no English language proficiency,
including services to persons who are deaf or blind. Interpreter and translation services shall be provided
as necessary to allow such participants meaningful access to the programs, services and benefits
provided by CONTRACTOR. Interpreter and translation services, including translation of
CONTRACTOR’s “vital documents” (those documents that contain information that is critical for accessing
CONTRACTOR’s services or are required by law) shall be provided to participants at no cost to the
participant. CONTRACTOR shall ensure that any employees, agents, subcontractors, or partners who
interpret or translate for a program participant, or who directly communicate with a program participant in a
language other than English, demonstrate proficiency in the participant's language and can effectively
communicate any specialized terms and concepts peculiar to CONTRACTOR’s services.
E. In compliance with the State mandated Culturally and Linguistically Appropriate
Services standards as published by the Office of Minority Health, CONTRACTOR must submit to
COUNTY for approval, within 60 days from date of contract execution, CONTRACTOR’s plan to address
all fifteen national cultural competency standards as set forth in the “National Standards on Culturally and
Linguistically Appropriate Services” (CLAS), attached hereto as Exhibit K, and incorporated herein by this
reference. County’s annual on-site review of CONTRACTOR shall include collection of documentation to
ensure all national standards are implemented. As the national competency standards are updated,
CONTRACTOR’s plan must be updated accordingly.
F. CONTRACTOR shall complete and submit county-issued CLAS self-assessment
annually. CONTRACTOR shall update CLAS plan as necessary.
33. CLEAN AIR AND WATER
In the event funding under this Agreement exceeds one hundred thousand dollars
($100,000.00), the CONTRACTOR must comply with all applicable standards, orders, or requirements
issued under section 306 of the Clean Air Act (42 U.S.C. 1857 (h)), section 506 of the Clean Water Act (33
U.S.C. 1368), Executive Order 11738, and Environmental Protection Agency Regulations (40 CFR part
32).
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34. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR each consider and represent themselves as covered
entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law
104-191(HIPAA) and agree to use and disclose protected health information as required by law.
COUNTY and CONTRACTOR acknowledge that the exchange of protected health
information between them is only for treatment, payment, and health care operations.
COUNTY and CONTRACTOR intend to protect the privacy and provide for the security of
Protected Health Information (PHI) pursuant to the Agreement in compliance with HIPAA, the Health
Information Technology for Economic and Clinical Health Act, Public Law 111-005 (HITECH), and
regulations promulgated thereunder by the U.S. Department of Health and Human Services (HIPAA
Regulations) and other applicable laws.
As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI,
as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) of the Code
of Federal Regulations (CFR).
Additionally, CONTRACTOR shall comply with the HIPAA requirements stated in Exhibit
C, “Drug Medi-Cal Specific Requirements.”
35. CHILD ABUSE REPORTING
CONTRACTOR shall utilize a procedure acceptable to the COUNTY to ensure that all of
CONTRACTOR’s employees, volunteers, consultants, subcontractors or agents performing services under
this Agreement shall report all known or suspected child abuse or neglect to one or more of the agencies
set forth in Penal Code § 11165.9. This procedure shall include having all of CONTRACTOR’s employees,
volunteers, consultants, subcontractors or agents performing services under this Agreement sign a
statement that he or she knows of and will comply with the reporting requirements set forth in Penal Code §
11166. The statement to be utilized by CONTRACTOR for reporting is set forth in Exhibit L, “Notice of
Child Abuse Reporting,” attached hereto and by this reference incorporated herein.
36. RESTRICTION ON DISTRIBUTION OF STERILE NEEDLES
CONTRACTOR shall adhere to the requirement that no funds shall be used to carry out any
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program of distributing sterile needles or syringes for the hypodermic injection of any illegal drug unless the
DHCS chooses to implement a demonstration syringe services program for intravenous drug users.
37. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
INFORMATION
This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
managed care entity as defined in 42 CFR § 455.101 455.104, and 455.106(a)(1),(2).
In accordance with 42 CFR §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2), the
following information must be disclosed by CONTRACTOR by completing Exhibit M “Disclosure of
Ownership and Control Interest Statement,” attached hereto and by this reference incorporated herein.
CONTRACTOR shall submit this form to the Department of Behavioral Health within thirty (30) days of
the effective date of this Agreement. Submissions shall be scanned pdf copies and are to be sent via
email to DBHAdministration@co.fresno.ca.us attention: Contracts Administration.
A. Name and address of any person(s) whether it be an individual or corporation with
an ownership or controlling interest in the disclosing entity or managed care entity.
1) Address must include the primary business address, every business
location and P.O. Box address(es).
2) Date of birth and Social Security Number for individuals.
3) Tax identification number for other corporations or entities with ownership
or controlling interest in the disclosing entity.
B. Any subcontractor(s) in which the disclosing entity has five (5) percent or more
interest.
C. Whether the person(s) with an ownership or controlling interest of the disclosing
entity is related to another person having ownership or controlling interest as a parent, spouse, sibling
or child. Including whether the person(s) with ownership or controlling interest of the disclosing entity is
related to a person (parent, spouse, sibling or child) with ownership or has five (5) percent or more
interest in any of its subcontractors.
D. Name of any other disclosing entity in which an owner of the disclosing entity has
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an ownership or control interest.
E. The ownership of any subcontractor with whom CONTRACTOR has had business
transactions totaling more than twenty-five thousand dollars ($25,000) during the 12-month period
ending on the date of the request; and
F. Any significant business transactions between CONTRACTOR and any wholly
owned supplier, or between CONTRACTOR and any subcontractor, during the five (5)year period
ending on the date of the request.
G. Any person(s) with an ownership or control interest in CONTRACTOR, or agent or
managing employee of CONTRACTOR; and
1) Has been convicted of a criminal offense related to that person's
involvement in any program under Medicare, Medicaid, or the title XX services program since the
inception of those programs.
H. The ownership of any subcontractor with whom CONTRACTOR has had
business transactions totaling more than twenty-five thousand dollars ($25,000) during the 12-month
period ending on the date of the request; and
I. Any significant business transactions between CONTRACTOR and any wholly
owned supplier, or between CONTRACTOR and any subcontractor, during the five (5) year period
ending on the date of the request.
38. CHANGE OF LEADERSHIP/MANAGEMENT
Any and all notices between COUNTY and CONTRACTOR(S) provided for or permitted
under this Agreement or by law, shall be in writing and shall be deemed duly served when personally
delivered to one of the parties, or in lieu of such personal service, when deposited in the United States
Mail, postage prepaid, addressed to such party.
In the event of any change in the status of CONTRACTOR’s leadership or management,
CONTRACTOR shall provide written notice to COUNTY within thirty (30) days from the date of change.
Such notification shall include any new leader or manager’s name, address and qualifications. “Leadership
or management” shall include any employee, member, or owner of CONTRACTOR who either a) directs
individuals providing services pursuant to this Agreement; b) exercises control over the manner in which
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services are provided; or c) has authority over CONTRACTOR’s finances.
39. NOTICES
The persons and their addresses having authority to give and receive notices under this
Agreement include the following:
COUNTY CONTRACTOR
Director, Fresno County See Exhibit A
Department of Behavioral Health
4441 East Kings Canyon
Fresno, CA 93702
All notices between the COUNTY and CONTRACTOR provided for or permitted under this
Agreement must be in writing and delivered either by personal service, by first-class United States mail, by
an overnight commercial courier service, or by telephonic facsimile transmission. A notice delivered by
personal service is effective upon service to the recipient. A notice delivered by first-class United States
mail is effective three COUNTY business days after deposit in the United States mail, postage prepaid,
addressed to the recipient. A notice delivered by an overnight commercial courier service is effective one
COUNTY business day after deposit with the overnight commercial courier service, delivery fees prepaid,
with delivery instructions given for next day delivery, addressed to the recipient. A notice delivered by
telephonic facsimile is effective when transmission to the recipient is completed (but, if such transmission is
completed outside of COUNTY business hours, then such delivery shall be deemed to be effective at the
next beginning of a COUNTY business day), provided that the sender maintains a machine record of the
completed transmission. For all claims arising out of or related to this Agreement, nothing in this section
establishes, waives, or modifies any claims presentation requirements or procedures provided by law,
including but not limited to the Government Claims Act (Division 3.6 of Title 1 of the Government Code,
beginning with section 810).
40. SEPARATE AGREEMENT
It is mutually understood by the parties that this Agreement does not, in any way, create
a joint venture among CONTRACTOR(S). By execution of this Agreement, CONTRACTOR(S)
understands that a separate Agreement is formed between each individual CONTRACTOR and
COUNTY.
//
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41. GOVERNING LAW
Venue for any action arising out of or related to this Agreement shall only be in Fresno
County, California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
42. SUPERSEDE
Effective January 1, 2019, this Agreement shall supersede in its entirety and render null
and void the Agreement between the parties for these same services identified in Drug Medi-Cal (DMC)
Master 16-360, and all amendments thereto; Residential Detoxification Agreement 15-245, and all
amendments thereto; and Adult/Perinatal Residential Master Agreement 16-295, and all amendments
thereto.
43. SEVERABILITY
The provisions of this Agreement are severable. The invalidity or unenforceability of
any one provision in the Agreement shall not affect the other provisions.
44. ENTIRE AGREEMENT
This Agreement, including all Exhibits, COUNTY’s RFSQ No. 18-064 and CONTRACTOR’s
responses thereto, constitutes the entire agreement between the CONTRACTOR and COUNTY with
respect to the subject matter hereof and supersedes all previous Agreement negotiations, proposals,
commitments, writings, advertisements, publications, and understanding of any nature whatsoever unless
expressly included in this Agreement.
1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day
2 and year first hereinabove written .
3
4 CONTRACTOR
5
6 SEE EXHIBIT A
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17 FOR ACCOUNTING USE ONLY :
18
19 ORG No.: 56302081
20 Account No .: 7295/0
Fund/Subclass : 0001/10000
21 Requisition No .: 5631810050
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COUNTY OF FRESNO
irperson of the Board of
County of Fresno
ATTEST:
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno , State of California
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Exhibit A
VENDOR PHONE NUMBER TYPE OF BUSINESS
Central California Recovery, Inc.(559) 273‐2942 501(c)3 Non‐Profit Corporation
Remit to:(559) 681‐1947
1204 W. Shaw Ave. #102
Fresno, CA 93711
Fresno New Connections, Inc.(559) 248‐1548 501(c)3 Non‐profit Corporation
Remit to:
4411 N. Cedar Ave. #108
Fresno, CA 93726
Kings View Corporation (559)251‐0100 x3011 501(c)3 Non‐profit Corporation
Remit to:
7170 N. Financial Drive, #110
Fresno, CA 93720
Mental Health Systems, Inc.(858) 573‐2600 501(c)3 Non‐profit Corporation
Remit to:
9465 Farnham St.
San Diego, CA 92123
Panacea Services, Inc.(559) 241‐0364 For Profit Corporation
Remit to:
3152 N. Millbrook Ave., Suite D/E
Fresno, CA 93703
Promesa Behavioral Health (559) 439‐5437 501(c)3 Non‐profit Corporation
Remit to:
7120 N. Marks Ave, #110
Fresno, Ca 93711
Transitions Children's Services (559) 222‐5437 501(c)3 Non‐profit Corporation
Remit to:
1945 N. Helm Ave, #101
Fresno, Ca 93727
Turning Point of Central California, Inc.(559) 732‐8086 501(c)3 Non‐profit Corporation
Remit to:
PO Box 7447
Visalia, CA 93290
WestCare California, Inc.(559) 251‐4800 501(c)3 Non‐profit Corporation
Remit to:
1900 N. Gateway Blvd, 100
Fresno, CA 93727
** A list of current provider sites can be found at:
https://www.co.fresno.ca.us/departments/behavioral‐health/substance‐use‐disorder‐services
DMC Services Vendor List
Revised 10/11/18 1 of 1
Exhibit B
Revised 09/20/18 1
Fresno County, Department of Behavioral Health
Drug Medi-Cal Organized Delivery System
Modality of Service Descriptions
Covered services under the Drug Medi-Cal Organized Delivery System (DMC-ODS) shall be
furnished in an amount, duration, and scope that is no less than the amount, duration, and scope
for the same services furnished to beneficiaries under fee-for-service Medicaid, as set forth in 42
CFR 440.230. Contractors shall ensure that the services are sufficient in amount, duration, or
scope to reasonably be expected to achieve the purpose for which the services are furnished.
Contractors may not arbitrarily deny or reduce the amount duration, or scope of a required
service solely because of diagnosis, type of illness, or condition of the beneficiary (IA III.C,
Covered Services).
Contractors are required to ensure services are provided timely. Timeliness is defined as no more
than ten (10) days from initial contact for non-emergency outpatient services, no more than three
(3) days from initial contact for first dose of NTP , no more than 48 hours from initial contact for
non-emergency residential services and no more than 24 hours from initial contact for urgent
services.
Placement in an appropriate level of care must be determined through an assessment based on
the American Society of Addiction Medicine (ASAM) criteria and prescribed by the contractor’s
medical director.
DRUG MEDI-CAL SERVICES:
OUTPATIENT SERVICES (ASAM LEVEL 1.0)
Outpatient services consist of up to nine (9) hours per week of medically necessary services for
adults and less than six (6) hours per week of services for adolescents.
Outpatient services shall include: assessment; treatment planning; individual and group
counseling; family therapy; beneficiary education; medication services; collateral services; crisis
intervention services; and discharge planning and coordination.
Services may be provided in-person, by telephone, or by telehealth in any appropriate setting in
the community.
INTENSIVE OUTPATIENT SERVICES (ASAM LEVEL 2.1)
Intensive outpatient involves structured programming provided to beneficiaries as medically
necessary for a minimum of nine (9) hours and a maximum of nineteen (19) hours per week for
adult perinatal and non-perinatal beneficiaries. Adolescents are provided a minimum of six (6)
and a maximum of nineteen (19) hours of service per week.
Exhibit B
Revised 09/20/18 2
Intensive outpatient services shall include: assessment; treatment planning; individual and/or
group counseling; beneficiary education; family therapy; medication services; collateral services;
crisis intervention services; and discharge planning and coordination.
Services may be provided in-person, by telephone, or by telehealth in any appropriate setting in
the community.
OPIOID (NARCOTIC) TREATMENT PROGRAMS (ASAM LEVEL 1.0)
Narcotic treatment programs services and regulatory requirements shall be provided in
accordance with Title 9, Chapter 4.
Pursuant to W&I Code, Section 14124.22, a Narcotic Treatment Program (NTP) contractor who
is also enrolled as a Medi-Cal provider may provide medically necessary treatment of concurrent
health conditions to Medi-Cal beneficiaries who are not enrolled in managed care plans as long
as those services are within the scope of the contractor’s practice. NTP contractors shall refer all
Medi-Cal beneficiaries that are enrolled in managed care plans to their respective managed care
plan to receive medically necessary medical treatment of their concurrent health conditions.
The diagnosis and treatment of concurrent health conditions of Medi-Cal beneficiaries that are
not enrolled in managed care plans by a NTP contractor may be provided within the Medi-Cal
coverage limits. When the services are not part of the substance use disorder (SUD) treatment
reimbursed pursuant to W&I Code, Section 14021.51, the services rendered shall be reimbursed
in accordance with the Medi-Cal program. Services reimbursable under this section shall include
all of the following:
1. Medical treatment visits;
2. Diagnostic blood, urine and x-rays;
3. Psychological and psychiatric tests and services;
4. Quantitative blood and urine toxicology assays; and
5. Medical supplies.
An NTP contractor who is enrolled as a Medi-Cal fee-for-service provider shall not seek
reimbursement from a beneficiary for SUD treatment services, if the NTP contractor bills the
services for treatment of concurrent health conditions to the Medi-Cal fee-for-service program.
NTP services shall only be provided by a licensed NTP to beneficiaries who meet medical
necessity criteria requirements.
Services shall be provided in accordance with an individualized beneficiary plan determined by a
licensed prescriber.
NTP contractors may offer and prescribe medications to beneficiaries covered under the DMC-
ODS formulary including methadone, buprenorphine, naloxone, and disulfiram.
Exhibit B
Revised 09/20/18 3
Services provided as part of an NTP shall include: assessment, treatment planning, individual
and group counseling, beneficiary education; medication services, collateral services, crisis
intervention services, medical psychotherapy and discharge services.
Beneficiaries shall receive between fifty (50) and two-hundred (200) minutes of counseling per
calendar month with a therapist or counselor, and, when medically necessary, additional
counseling services may be provided.
For an individual to receive ongoing NTP services, the Medical Director, licensed physician, or
LPHA must reevaluate that beneficiary’s medical necessity qualification at least annually
through the reauthorization process and determine that those services are still clinically
appropriate.
PERINATAL/NON-PERINATAL RESIDENTIAL SUBSTANCE USE DISORDER
TREATMENT SERVICES (EXCLUDING ROOM AND BOARD) (ASAM LEVELS 3.1,
3.3 and 3.5)
Residential services are provided in California Department of Health Care Services (DHCS)
(Department of Social Services for adolescents) licensed residential facilities that also have
DMC certification and an ASAM designation by DHCS as capable of delivering care consistent
with ASAM treatment criteria. The treatment portion of residential services is reimbursable
through Drug Medi-Cal.
There is no bed capacity limit for residential services.
Adults (21 and over): may receive up to two (2) non-continuous short-term residential regimens
per 365-day period. A short-term residential regimen is defined as one (1) residential stay in a
DHCS licensed facility for a maximum of ninety (90) days.
An adult beneficiary may receive one thirty (30) day extension per 365-day period, if that
extension is determined to be medically necessary.
Adolescents (under the age of 21): may receive up to two (2) non-continuous residential
regimens per 365-day period for a maximum of thirty (30) days. Adolescent beneficiaries may
receive one thirty (30) day extension per 365-day period, if that extension is determined to be
medically necessary. Adolescent beneficiaries receiving residential treatment shall be stabilized
as soon as possible and moved down to a less intensive level of treatment. Nothing in the DMC-
ODS or in this paragraph overrides any EPSDT requirements.
Perinatal beneficiaries: If determined to be medically necessary, perinatal beneficiaries may
receive a longer length of stay than those described above. Perinatal beneficiaries may receive
lengths of stay up to the length of the pregnancy and postpartum period (60 days after the
pregnancy ends).
Exhibit B
Revised 09/20/18 4
Residential contractor(s) must seek prior authorization for residential services following the
established Substance Use Treatment and Authorization Request (STAR) timeframes, found in
the Provider Manual.
WITHDRAWAL MANAGEMENT (WM– ASAM LEVELS 1, 2, 3.2, 3.7 and 4)
The treatment portion of withdrawal management service is reimbursable through Drug Medi-
Cal.
Withdrawal management (WM) services are prescribed based on an individual assessment using
the ASAM criteria. The components of WM include: intake, observation, medication services as
determined necessary and discharge/transition planning services. Contractor(s) shall ensure
beneficiaries receiving both residential and outpatient WM services are monitored during the
detoxification process.
Contractor(s) shall provide medically necessary habilitative and rehabilitative services in
accordance with an individualized treatment plan prescribed by a licensed physician or licensed
prescriber.
ASAM 3.7-WM and 4-WM services are part of the DMC-ODS continuum of care but are offered
through with the Medi-Cal fee-for-service Managed Care Plans, Anthem Blue Cross and
CalViva Health. If a beneficiary is determined to be in need of this level of care, the provider
should coordinate the transition to a provider under one of the above-mentioned Managed Care
Plans for treatment.
ADDITIONAL MEDICATION ASSISTED TREATMENT (MAT)
Additional MAT involves the ordering, prescribing, administering, and monitoring of
medications for substance use disorders. Medically necessary services are provided in
accordance with an individualized treatment plan determined by a licensed physician or licensed
prescriber.
The program providing MAT is responsible for the prescribing, ordering, and monitoring of
medications to beneficiaries receiving SUD treatment. Allowable medications include:
buprenorphine; naltrexone; disulfiram; acamprosate; and naloxone.
CASE MANAGEMENT SERVICE
Case management services are defined as a service that assists a beneficiary to access needed
medical, educational, social, prevocational, vocational, rehabilitative, or other community
services.
Case management services shall focus on coordination of SUD care, integration around primary
care especially for beneficiaries with a chronic SUD, and interaction with the criminal justice
system, if needed.
Exhibit B
Revised 09/20/18 5
Case management services will be provided by contractors once the beneficiary is enrolled in an
SUD program. Case management services will be monitored by County during the annual site
review.
Case management services may be provided by a Licensed Practitioner of the Healing Arts or
certified counselor.
Contractors shall use case management services to coordinate with physical and/or mental health
systems of care.
Case management services may be provided in person, by telephone, or by telehealth with the
beneficiary and may be provided anywhere in the community.
Case management shall be consistent with and shall not violate confidentiality of alcohol or drug
beneficiaries as set forth in 42 CFR Part 2, and California law.
RECOVERY SERVICES
Recovery services are available to beneficiaries who have completed an SUD treatment program
and must be addressed in the beneficiary’s discharge plan. Recovery services can be utilized
when the beneficiary is triggered, when the beneficiary has relapsed or simply as a measure to
prevent relapse.
Contractors that do not opt to make recovery services available must refer beneficiaries to a
contractor that provides recovery services.
Recovery Services shall include:
1. Outpatient counseling services in the form of individual or group counseling to stabilize
the beneficiary and then reassess if the beneficiary needs further care;
2. Recovery Monitoring: Recovery coaching, monitoring via telephone and internet;
3. Substance Abuse Assistance: Peer-to-peer services (once Fresno County has
implemented a DHCS-approved Peer Support Specialist Training Plan) and relapse
prevention;
4. Education and Job Skills: Linkages to life skills, employment services, job training, and
education services;
5. Family Support: Linkages to childcare, parent education, child development support
services, family/marriage education;
6. Support Groups: Linkages to self-help and support, spiritual and faith-based support; and
7. Ancillary Services: Linkages to housing assistance, transportation, case management,
individual services coordination.
The contractor shall provide:
1. Recovery services to beneficiaries as medically necessary;
2. Beneficiaries with access to recovery services after completing their course of treatment;
and
Exhibit B
Revised 09/20/18 6
3. Recovery services in person, by telephone, or by telehealth with the beneficiary.
PHYSICIAN CONSULTATION
Physician Consultation services include DMC physicians’ consulting with addiction medicine
physicians, addiction psychiatrists or clinical pharmacists. Physician consultation services are
designed to assist DMC physicians by allowing them to seek expert advice with regards to
designing treatment plans for specific DMC-ODS beneficiaries. Physician consultation services
may address medication selection, dosing, side effect management, adherence, drug-drug
interactions, or level of care considerations.
County will provide DMC certified contractors with access to one or more American Board of
Addiction Medicine-certified physicians or pharmacists in order to facilitate consultations.
Access to physician consultation will only be available to DMC contracted treatment providers.
Exhibit B
Revised 09/20/18 7
NON-DMC FUNDED SERVICES:
Non-DMC eligible beneficiaries will have access to the same services as DMC beneficiaries with
costs reimbursed through other sources. These services, available to all perinatal and non-
perinatal adults and adolescents, include outpatient, intensive outpatient, additional medication
assisted treatment and residential treatment, including withdrawal management. Case
management, physician consultation and recovery services are also available to non-DMC
eligible beneficiaries as a component of the outpatient and residential treatment modalities.
Recovery residences are available to DMC and non-DMC eligible beneficiaries who are actively
engaged in outpatient SUD treatment or recovery services.
Room and Board for residential treatment and withdrawal management services is not eligible
for reimbursement through DMC. These costs will be covered with other non-DMC funding
sources.
Exhibit C
1
Revised 10/16/18
DRUG MEDI-CAL INTERGOVERNMENTAL AGREEMENT
REQUIREMENTS
Fresno County, through the Department of Behavioral Health, makes substance
use disorder treatment services available throughout the county to Medi-Cal
eligible beneficiaries through funds provided under an Intergovernmental
Agreement with the California Department of Health Care Services. The County,
and all contracted providers, must comply with the terms of the Intergovernmental
Agreement, and any amendments thereto, including but not limited to the
following:
1. STATE ALCOHOL AND DRUG REQUIREMENTS
A. INDEMNIFICATION
The CONTRACTOR agrees to indemnify, defend and save harmless
the State, its officers, agents and employees from any and all claims and losses accruing
or resulting to any and all contractors, subcontractors, materialmen, laborers and any
other person, firm or corporation furnishing or supplying work, services, materials or
supplies in connection with the performance of this Agreement and from any and all
claims and losses accruing or resulting to any person, firm or corporation who may be
injured or damaged by the CONTRACTOR in the performance of this Agreement.
B. INDEPENDENT CONTRACTOR
The CONTRACTOR and the agents and employees of
CONTRACTOR, in the performance of this Agreement, shall act in an independent
capacity and not as officers or employees or agents of State of California.
C. CONTROL REQUIREMENTS
This Agreement is subject to all applicable Federal and State laws,
regulations and standards. CONTRACTOR(S) shall establish written procedures
consistent with State-County Contract requirements. The provisions of this Agreement
are not intended to abrogate any provisions of law or regulation existing or enacted during
the term of this Agreement.
D. 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
Part 2, Title 42, Code of Federal Regulations; 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.
E. REVENUE COLLECTION POLICY
Exhibit C
2
Revised 10/16/18
CONTRACTOR shall conform to all policies and procedures
regarding revenue collection issued by the State under the provisions of the Health and
Safety Code, Division 10.5.
F. EXPENDITURE OF STATE GENERAL AND FEDERAL FUNDS
CONTRACTOR agrees that all funds paid out by the State shall be
used exclusively for providing alcohol and/or drug program services, administrative costs,
and allowable overhead.
G. ACCESS TO SERVICES
CONTRACTOR shall provide accessible and appropriate services in
accordance with Federal and State statutes and regulations to all eligible persons.
H. REPORTS
CONTRACTOR agrees to participate in surveys related to the
performance of this Agreement and expenditure of funds and agrees to provide any such
information in a mutually agreed upon format.
I. AUDITS
All State and Federal funds furnished to the CONTRACTOR(S)
pursuant to this Agreement along with related patient fees, third party payments, or other
related revenues and funds commingled with the foregoing funds are subject to audit by
the State. The State may audit all alcohol and drug program revenue and expenditures
contained in this Agreement for the purpose of establishing the basis for the subsequent
year's negotiation.
J. RECORDS MAINTENANCE
1) CONTRACTOR shall maintain books, records, documents,
and other evidence necessary to monitor and audit this Agreement.
2) CONTRACTOR shall maintain adequate program and fiscal
records relating to individuals served under the terms of this Agreement, as required, to
meet the needs of the State in monitoring quality, quantity, fiscal accountability, and
accessibility of services. Information on each individual shall include, but not be limited
to, admission records, patient and participant interviews and progress notes, and records
of service provided by various service locations, in sufficient detail to make possible an
evaluation of services provided and compliance with this Agreement.
2. FEDERAL CERTIFICATIONS
CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBILITY AND VOLUNTARY EXCLUSION LOWER TIER COVERED
TRANSACTIONS
A. DBH and CONTRACTOR recognize that Federal assistance funds
Exhibit C
3
Revised 10/16/18
will be used under the terms of this Agreement. For purposes of this section, DBH will be
referred to as the "prospective recipient".
B. This certification is required by the regulations implementing
Executive Order 12549, Debarment and Suspension, 29 CFR Part 98, section 98.510,
Participants' responsibilities. The regulations were published as Part VII of the May 26,
1988 Federal Register (pages 19160-19211).
1) The prospective recipient of Federal assistance funds certifies
by entering this Agreement, that neither it nor its principals are presently debarred,
suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
participation in this transaction by any Federal department or agency.
2) The prospective recipient of funds agrees by entering into this
Agreement, that it shall not knowingly enter into any lower tier covered transaction with a
person who is debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the Federal department or
agency with which this transaction originated.
3) Where the prospective recipient of Federal assistance funds is
unable to certify to any of the statements in this certification, such prospective participant
shall attach an explanation to this Agreement.
4) The CONTRACTOR shall provide immediate written notice to
DBH if at any time CONTRACTOR learns that its certification in this clause of this
Agreement was erroneous when submitted or has become erroneous by reason of
changed circumstances.
5) The prospective recipient further agrees that by entering into
this Agreement, it will include a clause identical to this clause of this Agreement, and titled
"Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion
Lower Tier Covered Transactions", in all lower tier covered transactions and in all
solicitations for lower tier covered transactions.
6) The certification in this clause of this Agreement is a material
representation of fact upon which reliance was placed by COUNTY when this transaction
was entered into.
3. SMOKING PROHIBITION REQUIREMENTS
CONTRACTOR shall comply with Public Law 103-227, also known as the
Pro-Children Act of 1994 (20 USC Section 6081, et seq.), and with California Labor Code
Section 6404.5, the California Smoke-Free Workplace Law.
4. TRAFFICKING IN PERSONS PROVISIONS – PRIVATE ENTITY
CONTRACTOR shall conform to all Federal statutes and regulations
prohibiting trafficking in persons, as well as trafficking-related activities, including, but
Exhibit C
4
Revised 10/16/18
not limited to the trafficking of persons provisions in Section 106(g) of the Trafficking
Victims Protection Act of 2000 (TVPA) as amended by Section 1702.
CONTRACTOR, CONTRACTOR’s employees, subrecipients, and
subrecipients’ employees may not:
A) Engage in severe forms of trafficking in persons during the period
of time that the award is in effect;
B) Procure a commercial sex act during the period of time that the
award is in effect; or
C) Use forced labor in the performance of the award or subawards
under the award.
This agreement may be unilaterally terminated, without penalty, if
CONTRACTOR or a subrecipient that is a private entity is determined to have violated
a prohibition of the TVPA or has an employee who is determined by the DBH Director
or her designee to have violated a prohibition of the TVPA through conduct that is
either associated with performance under the award or imputed to the CONTRACTOR
or their subrecipient using the standards and due process for imputing the conduct of
an individual to an organization that are provided in 2 C.F.R. Part 180, “OMB
Guidelines to Agencies on Government-wide Debarment and Suspension
(Nonprocurement).
CONTRACTOR must inform the DBH Director or her designee
immediately of any information received from any source alleging a violation of a
prohibition of the TVPA.
CONTRACTOR must sign a certification annually acknowledging the
Trafficking Victims Protection Act of 2000 requirements (TVPA Certification), attached
hereto as Attachment A, incorporated herein by reference and made part of this
Agreement and must require all employees to complete annual TVPA training.
5. UNLAWFUL USE OF DRUGS AND ALCOHOL OR UNLAWFUL USE
MESSAGES
CONTRACTOR shall ensure that information produced with Federal funds
pertaining to drug and alcohol related programs contains a clearly written statement that
there shall be no unlawful use of drugs or alcohol associated with the program.
Additionally, CONTRACTOR shall ensure that no aspect of the program includes any
message in materials, curricula, teachings, or promotion of the responsible use, if the use
is unlawful, of drugs or alcohol pursuant to Health and Safety Code (HSC) 11999-
11999.3.
CONTRACTOR must sign the Unlawful Use of Drugs and Alcohol
Certification, attached hereto as Attachment B, incorporated herein by reference and
made part of this Agreement agreeing to uphold the obligations of HSC 11999 – 11999.3.
Exhibit C
5
Revised 10/16/18
This agreement may be unilaterally terminated, without penalty, if
CONTRACTOR or a subcontractor that is a private entity is determined to have violated a
prohibition of the Unlawful Use of Drugs and Alcohol message or has an employee who is
determined by the DBH Director or her designee to have violated a prohibition of the
Unlawful Use of Drugs and Alcohol message.
6. CONFIDENTIALITY OATH
CONTRACTOR shall ensure that all of its employees sign a written
confidentiality oath, attached hereto as Attachment C, before they begin employment
with CONTRACTOR and shall renew said document annually thereafter.
CONTRACTOR shall retain each employee’s written confidentiality oath for COUNTY
and DHCS inspection for a period of six (6) years following the termination of this
agreement.
7. CONTROL REQUIREMENTS
Performance under this Agreement is subject to all applicable Federal and
State laws, regulations and standards. In accepting the State drug and alcohol
combined program allocation pursuant to California Health and Safety Code section
11757, CONTRACTOR shall establish written accounting procedures consistent with
applicable Federal and State laws, regulations and standards, and shall be held
accountable for audit exceptions taken by the State or COUNTY for failure to comply
with these requirements. These requirements include, but may not be limited to, those
set forth in this Agreement, and:
A. Division 10.5 of the California Health and Safety Code;
B. California Government Code sections 16366.1 through 16367.9
and 53130 through 53138;
C. Title 9, Division 4 of the California Code of Regulations;
D. 42 United States Code (U.S.C.) section 300x-5;
E. 31 U.S.C. sections 7501-7507 (Single Audit Act of 1984; Single
Audit Act Amendments of 1996);
F. 2CFR Part 200 (Uniform Administrative Requirements, Cost
Principles, and Audit Requirements for Federal Awards); and
G. Title 45, Part 96, Subparts B, C and L of the Code of Federal
Regulations (Block Grants).
8. CULTURALLY COMPETENT SERVICES
CONTRACTOR shall ensure equal access to quality care by diverse
populations by adopting the federal Office of Minority Health Culturally and
Linguistically Appropriate Service (CLAS) national standards and complying with 42
Exhibit C
6
Revised 10/16/18
CFR 438.206(c)(2). CONTRACTOR’s policies, procedures, and practices must be
consistent with the principles outlined and are embedded in the organizational
structure, as well as being upheld in day-to-day operations. CONTRACTOR shall
promote the delivery of services in a culturally competent manner to all beneficiaries,
including those with limited English proficiency and diverse cultural and ethnic
backgrounds, disabilities, and regardless of gender, sexual orientation or gender
identity.
9. ADA CONSIDERATIONS
CONTRACTOR shall ensure that physical access, reasonable
accommodations, and accessible equipment are available for Medicaid beneficiaries
with physical or mental disabilities.
10. ADDITIONAL INTERGOVERNMENTAL AGREEMENT RESTRICTIONS
This Agreement is subject to any additional restrictions, limitations,
conditions, or statutes enacted or amended by the federal or state governments, which
may affect the provisions, terms, or funding of this Agreement in any manner.
11. NULLIFICATION OF DMC-ODS SERVICES
The parties agree that failure of COUNTY, or CONTRACTOR, to comply
with W&I section 14124.24, the Special Terms and Conditions, and this Agreement,
shall be deemed a breach that results in the termination of the State-County
Intergovernmental Agreement for cause. In the event of a breach, the DMC-ODS
services shall terminate. The COUNTY shall immediately begin providing DMC services
to the beneficiaries in accordance with the State Plan.
12. HATCH ACT
CONTRACTOR shall comply with the provisions of the Hatch Act (Title 5
USC, Sections 1501-1508), which limit the political activities of employees whose
principal employment activities are funded in whole or in part with federal funds.
13. LIMITATION ON USE OF FUNDS FOR PROMOTION OF
LEGALIZATION OF CONTROLLED SUBSTANCES
CONTRACTOR is prohibited from using funds made available through this
Agreement for any activity that promotes the legalization of any drug or other
substance included in Schedule I of Section 202 of the Controlled Substances Act (21
USC 812).
14. NONDISCRIMINATION IN EMPLOYMENT AND SERVICES
CONTRACTOR certifies that under the laws of the United States and the
State of California, incorporated into this Agreement by reference and made a part
Exhibit C
7
Revised 10/16/18
hereof as if set forth in full, CONTRACTOR shall not unlawfully discriminate against
any person.
15. FEDERAL LAW REQUIREMENTS
CONTRACTOR shall comply with the following Federal law requirements:
A. Title VI of the Civil Rights Act of 1964, Section 2000d, as amended,
prohibiting discrimination based on race, color, or national origin in
federally funded programs.
B. Title IX of the education amendments of 1972 (regarding education
and programs and activities), if applicable.
C. Title VIII of the Civil Rights Act of 1968 (42 USC 3601 et seq.)
prohibiting discrimination on the basis of race, color, religion, sex,
handicap, familial status or national origin in the sale or rental of
housing.
D. Age Discrimination Act of 1975 (45 CFR Part 90), as amended (42
USC Sections 6101 – 6107), which prohibits discrimination on the
basis of age.
E. Age Discrimination in Employment Act (29 CFR Part 1625).
F. Title I of the Americans with Disabilities Act (29 CFR Part 1630)
prohibiting discrimination against the disabled in employment.
G. Americans with Disabilities Act (28 CFR Part 35) prohibiting
discrimination against the disabled by public entities.
H. Title III of the Americans with Disabilities Act (28 CFR Part 36)
regarding access.
I. Rehabilitation Act of 1973, as amended (29 USC Section 794),
prohibiting discrimination on the basis of individuals with disabilities.
J. Executive Order 11246 (42 USC 2000(e) et seq. and 41 CFR Part
60) regarding nondiscrimination in employment under federal
contracts and construction contracts greater than $10,000 funded
by federal financial assistance.
K. Executive Order 13166 (67 FR 41455) to improve access to federal
services for those with limited English proficiency.
L. The Drug Abuse Office and Treatment Act of 1972, as amended,
relating to nondiscrimination on the basis of drug abuse.
M. The Comprehensive Alcohol Abuse and Alcoholism Prevention,
Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as
Exhibit C
8
Revised 10/16/18
amended, relating to nondiscrimination on the basis of alcohol
abuse or alcoholism.
16. STATE LAW REQUIREMENTS
CONTRACTOR shall comply with the following State law requirements:
A. Fair Employment and Housing Act (Government Code Section
12900 et seq.) and the applicable regulations promulgated
thereunder (California Administrative Code, Title 2, Section 7285.0
et seq.).
B. Title 2, Division 3, Article 9.5 of the Government Code,
commencing with Section 11135.
C. Title 9, Division 4, Chapter 8, commencing with Section 10800.
D. No state or Federal funds shall be used by COUNTY, or
CONTRACTOR, for sectarian worship, instruction, and/or
proselytization. No state funds shall be used by CONTRACTOR, or
CONTRACTOR, to provide direct, immediate, or substantial
support to any religious activity.
E. Noncompliance with the requirements of nondiscrimination in
services shall constitute grounds for state to withhold payments
under this Agreement or terminate all, or any type, of funding
provided hereunder.
17. INVESTIGATIONS AND CONFIDENTIALITY OF ADMINISTRATIVE
ACTIONS
COUNTY acknowledges that if a DMC provider is under investigation by
DHCS or any other state, local or federal law enforcement agency for fraud or abuse,
DHCS may temporarily suspend CONTRACTOR from the DMC program, pursuant to
W&I Code, Section 14043.36(a). Information about CONTRACTOR’s administrative
sanction status is confidential until such time as the action is either completed or
resolved. The DHCS may also issue a Payment Suspension to a provider pursuant to
W&I Code, Section 14107.11 and Code of Federal Regulations, Title 42, section
455.23. The COUNTY is to withhold payments from a DMC provider during the time a
Payment Suspension is in effect. COUNTY has executed a Confidentiality Agreement
that permits DHCS to communicate with COUNTY concerning CONTRACTOR(S) that
are subject to administrative sanctions.
18. COUNSELOR CERTIFICATION
CONTRACTOR shall ensure that any counselor or registrant providing
intake, assessment of need for services, treatment or recovery planning, individual or
Exhibit C
9
Revised 10/16/18
group counseling to participants, patients, or residents in a DHCS licensed or certified
program is required to be certified as defined in Title 9, Division 4, Chapter 8.
19. ADMISSION DISCRIMINATION
CONTRACTOR shall accept individuals eligible for admission in the order
in which they apply without restriction, up to the limits set under the State-County
Intergovernmental Agreement. CONTRACTOR shall not, based on health status or
need for health care services, discriminate against individuals eligible for admission.
CONTRACTOR shall not discriminate against individuals eligible for admission based
on race, color, national origin, ancestry, religion, sex, marital status, sexual orientation,
gender, gender identity, age, or disability and will not use any policy or practice that
has the effect of discriminating on the basis of race, color, or national origin, ancestry,
religion, sex, marital status, sexual orientation, gender, gender identity, age, or
disability. CONTRACTOR shall ensure that beneficiaries that meet medical necessity
for Medication Assisted Treatment (MAT) receive the same access to care as non-MAT
beneficiaries.
CONTRACTOR shall provide information on how to file a discrimination
complaint with the United States Department of Health and Human Services Office of
Civil Rights if there is a concern of discrimination based on race, color, national origin,
age, disability or sex.
20. SUBCONTRACTUAL REQUIREMENTS
CONTRACTOR shall fulfill contractual requirements of delegated services
or activities in accordance with 42 CFR §438.230 and shall perform the delegated
activities and reporting responsibilities in compliance with COUNTYs State-County
Intergovernmental Agreement obligations. CONTRACTOR shall comply with all
applicable Medicaid laws and regulations, including applicable sub-regulatory guidance
and contract provisions.
CONTRACTOR shall not bill beneficiaries for covered services under this
agreement in excess of the amount that would be owed by the individual if the
COUNTY had directly provided the services (42 U.S.C. 1396u-2(b)(6)(C)).
21. INSPECTION AND AUDIT OF RECORDS AND ACCESS TO
FACILITIES
CONTRACTOR agrees that COUNTY, DHCS, CMS, the HHS Inspector
General, the Comptroller General, or their designees have the right to audit, evaluate,
and inspect any books, records, contracts, computer or other electronic systems of
CONTRACTOR, or of the CONTRACTOR’s sub-contractor, that pertain to any aspect of
services and activities performed, or determination of amounts payable under
COUNTY’s contract with DHCS. CONTRACTOR shall make available, at any time, for
purposes of an audit, evaluation, or inspection, its premises, physical facilities,
equipment, books, records, contracts, computer or other electronic systems relating to
Exhibit C
10
Revised 10/16/18
its Medicaid enrollees. The right to audit will exist through 10 years from the final date of
the contract period or from the date of completion of any audit, whichever is later.
22. GRIEVANCE
CONTRACTOR shall comply with Grievance procedures set forth in the
State-County Intergovernmental Agreement, the Provider Manual and the Consumer
Handbook.
CONTRACTOR shall make the following grievance information available
to all beneficiaries:
A. Beneficiary’s right to a State Fair Hearing and how to obtain a
hearing as well as representation rules.
B. Beneficiary’s right to file grievances and appeals, including the
requirements and timeframes for filing.
C. Beneficiary’s right to give written consent to allow CONTRACTOR
or legal representative, acting on behalf of the beneficiary, to file an appeal.
D. Beneficiary may file a grievance orally or in writing to DHCS or
COUNTY.
E. The availability of assistance with filing grievances and appeals.
F. The toll-free number to file oral grievances and appeals.
G. Beneficiary’s right to request continuation of benefits during an
appeal or state fair hearing filing although the beneficiary may be liable for the cost of
any continued benefits if the action is upheld.
H. Any state determined contractor’s appeal rights to challenge the
failure of the COUNTY to cover a service.
23. GREIVANCE AND APPEALS RECORDKEEPING REQUIREMENTS
CONTRACTOR shall retain beneficiary grievance and appeal records as
referenced in 42 CFR §438.416, for a period of no less than ten (10) years. Beneficiary
grievance and appeal data shall include a general description of the reason for the
grievance or appeal, the date the grievance or appeal was received, the date of each
review or, if applicable, review meeting, the resolution and date of resolution at each
level of the grievance or appeal and the name of the covered person for whom the
grievance or appeal was filed. The record must be accurately maintained in a manner
accessible to DHCS and available upon request to CMS.
24. BENEFICIARY INFORMING AND TRANSLATION SERVICES
CONTRACTOR shall make written and verbal information available to
beneficiaries in their language of choice.
Exhibit C
11
Revised 10/16/18
Written material: CONTRACTOR shall use COUNTY’s written/translated
materials that are critical to obtaining services, including the provider directory,
beneficiary handbook, appeal and grievance notices, and denial and termination
notices, available in the prevalent non–English languages. All other CONTRACTOR
specific written materials must be made available in the prevalent non-English
languages. CONTRACTOR shall ensure that written materials are made available in
alternative formats upon request of the potential beneficiary or beneficiary at no cost.
Written materials shall include taglines in the prevalent non-English languages, as well
as large print, explaining the availability of written translation or oral interpretation to
understand the information provided.
Auxiliary aids: CONTRACTOR shall ensure auxiliary aids and services
shall also be made available upon request of the potential beneficiary or beneficiary at
no cost.
Interpretation services: CONTRACTOR shall make interpretation services
available free of charge to each beneficiary. This includes oral interpretation and the
use of auxiliary aids (such as TTY/TDY and American Sign Language) and services
including qualified interpreters for individuals with disabilities. Oral interpretation
requirements apply to all non–English languages, not just those that DHCS identifies
as prevalent. Pursuant to WIC 14029.91(a)(1)(B), Oral interpretation services shall be
provided by an interpreter that, at a minimum, meets all of the following qualifications:
A. Demonstrated proficiency in both English and the target language;
B. Knowledge in both English and the target language of health care
terminology and concepts relevant to health care delivery systems; and
C. Adheres to generally accepted interpreter ethics principle, including
client confidentiality.
CONTRACTOR shall notify its beneficiaries that oral interpretation is
available for any language and written translation is available in prevalent languages
and that auxiliary aids and services are available upon request, at no cost and in a
timely manner for non-English speaking/reading/writing beneficiaries and beneficiaries
with disabilities.
Pursuant to 14029.91(a)(1)(C), CONTRACTOR shall not require a
beneficiary with limited English proficiency to provide his or her own interpreter or rely
on a staff member who does not meet the qualifications described above.
CONTRACTOR shall not rely on an adult or minor child accompanying the
limited-English-proficient beneficiary to interpret or facilitate communication except
under the circumstances described in WIC Section 14029.91(a)(1)(D) for emergencies
and upon request that the accompanying adult provide assistance.
Exhibit C
12
Revised 10/16/18
Pursuant to 45 CFR 92.201, CONTRACTOR shall not require a
beneficiary with limited English proficiency to accept language assistance services.
25. MEMBER HANDBOOK
CONTRACTOR shall utilize COUNTY developed member handbook and
issue to beneficiaries at intake. Member handbooks can also be made available by
mailing a printed copy of the information to the beneficiary’s mailing address, emailing
after obtaining the beneficiary’s agreement to receive information by email, providing
direction in paper or electronic form to the COUNTY website or any other method that
can reasonably be expected to result in the beneficiary receiving that information.
26. TIMELY ACCESS REQUIREMENTS
CONTRACTOR shall meet DHCS and COUNTY standards for timely
access to care and services, taking into account the urgency of the need for services.
CONTRACTORs must offer hours of operation that are no less than the hours of
operation offered to commercial beneficiaries or comparable to Medicaid FFS, if
CONTRACTOR services only Medicaid beneficiaries. Timeliness standards include,
but are not limited to:
A. Initial contact to first face-to-face appointment – 10 business days
B. Initial contact to first dose of NTP – 3 business days
C. Timeliness of services for Urgent Conditions – 1 business day
CONTRACTOR shall ensure that medical attention for emergency and
crisis medical conditions are provided immediately.
27. CARE COORDINATION
CONTRACTOR and COUNTY shall comply with the care and coordination
requirements of the State-County Intergovernmental Agreement, Exhibit A, Attachment
I, II.E.3. CONTRACTOR shall ensure that each beneficiary has an ongoing source of
care appropriate to his or her needs and shall ensure a person or entity within their
organization is formally designated as primarily responsible for coordinating the
services accessed by the beneficiary. The beneficiary shall be provided information on
how to contact their case manager. CONTRACTOR shall coordinate services between
levels of care, with services the beneficiary receives from any other managed care
organization and the services the beneficiary receives from community and social
support providers. Care coordination efforts shall be accurately documented in
beneficiary’s chart to be verified during COUNTY chart audits conducted at least
annually.
CONTRACTOR shall make a best effort to conduct an initial screening of
each beneficiary’s ancillary needs, within thirty (30) calendar days of the effective date
of admission for all new beneficiaries, including subsequent attempts if the initial
attempt to contact the beneficiary is unsuccessful.
Exhibit C
13
Revised 10/16/18
CONTRACTOR shall ensure that it maintains and shares, as appropriate,
a beneficiary health record in accordance with professional standards.
CONTRACTOR shall ensure that in the process of coordinating care, each
beneficiary’s privacy is protected in accordance with the privacy requirements in 45
CFR parts 160 and 164 subparts A and E and 42 CFR Part 2, to the extent that they
are applicable.
CONTRACTOR shall ensure that beneficiaries are aware of and are
referred to, when appropriate, recovery supports and services immediately after
discharge or upon completion of an acute care stay.
28. AUTHORIZATION OF SERVICES
CONTRACTOR shall adhere to COUNTY’s written policies and
procedures, outlined in the Provider Manual, for authorization of services.
29. PERFORMANCE IMPROVEMENT PROJECTS
CONTRACTOR shall assist, when requested by COUNTY, in developing
and reviewing annual Performance Improvement Projects including but not limited to
identifying a clinical and a non-clinical problem, brainstorming causes and barriers,
implementation of interventions for the identified problems, and analysis of
interventions. CONTRACTOR shall assist in planning and initiation of activities for
increasing or sustaining improvement.
30. CONTRACTOR DMC CERTIFICATION
DMC certified contractors must revalidate DMC certification with DHCS
every five (5) years. Failure to revalidate DMC certification within 120 days following
the expiration of every five (5) year period will result in contract termination. COUNTY
shall terminate CONTRACTOR immediately upon notification from DHCS that the
CONTRACTOR cannot be enrolled, or the expiration of one 120-day period without
enrollment of CONTRACTOR, and shall notify affected beneficiaries. CONTRACTOR
shall ensure enrollment with DHCS as a Medicaid provider consistent with the provider
disclosure, screening and enrollment requirements.
DMC certified CONTRACTORs shall be subject to continuing certification
requirements at least once every five years. DHCS may allow the CONTRACTOR to
continue delivering covered services to beneficiaries at a site subject to on-site review
by DHCS as part of the recertification process prior to the date of the on-site review,
provided the site is operational, the certification remains valid, and has all required fire
clearances. DHCS shall conduct unannounced certification and recertification site visits
at clinics pursuant to W&I Code, Section 14043.7.
Exhibit C
14
Revised 10/16/18
31. PROGRAM INTEGRITY REQUIREMENTS
CONTRACTOR shall implement and maintain arrangements or procedures
that are designed to detect and prevent fraud, waste, and abuse. CONTRACTOR shall
maintain written policies, procedures, and standards of conduct that articulate
CONTRACTORs commitment to comply with all applicable requirements and
standards under the State-County Intergovernmental Agreement, and all applicable
Federal and State requirements. CONTRACTOR shall establish and implement
procedures and a system with dedicated staff for routine internal monitoring and
auditing of compliance risks, prompt response to compliance issues as they are raised,
investigation of potential compliance problems as identified in the course of self-
evaluation and audits, correction of such problems promptly and thoroughly (or
coordination of suspected criminal acts with law enforcement agencies) to reduce the
potential for recurrence, and ongoing compliance.
CONTRACTOR shall provide reports to COUNTY within 60 calendar days
when it has identified an overpayment. COUNTY shall provide a mechanism for
reporting and collecting overpayment.
CONTRACTOR shall retain information regarding data, information, and
documentation for beneficiary encounter data specified in 42 CFR §§438.604, 438.606,
438.608, and 438.610 for a period of no less than 10 years. (INTERGOVERNMENTAL
AGREEMENT P.5)
CONTRACTOR shall not knowingly have a relationship with a director,
officer or partner of CONTRACTOR, a subcontractor of CONTRACTOR, a person with
beneficial ownership of five (5) percent or more of CONTRACTOR’s equity or a
network provider or person with an employment, consulting or other arrangement with
the CONTRACTOR for the provision of items and services that are significant and
material to the CONTRACTOR’s obligations under this Agreement with the following:
A. An individual or entity that is debarred, suspended, or otherwise
excluded from participating in procurement activities under the
Federal Acquisition Regulation or from participating in non-
procurement activities under regulations issued under Executive
Order No. 12549 or under guidelines implementing Executive Order
No. 12549.
B. An individual or entity who is an affiliate, as defined in the Federal
Acquisition Regulation at 48 CFR 2, Section 101, of a person
described above.
CONTRACTOR shall not have a relationship with an individual or entity
that is excluded from participation in any Federal Health Care Program under section
1128 or 1128A of the Act.
Exhibit C
15
Revised 10/16/18
32. CONTRACTOR SPECIFICATIONS
CONTRACTOR shall ensure that professional staff shall be licensed,
registered, certified or recognized under California scope of practice statutes.
Professional staff shall provide services within their individual scope of practice and
receive supervision required under their scope of practice laws. CONTRACTOR shall
ensure that professional staff (LPHAs) receive a minimum of five (5) hours of
continuing education related to addiction medicine each year. Copies of these
certifications and licenses shall be maintained in staff’s personnel files and records
shall be made available to COUNTY upon request.
CONTRACTOR shall ensure that non-professional staff receive
appropriate onsite orientation and training prior to performing assigned duties. A
professional and/or administrative staff shall supervise non-professional staff.
Professional and non-professional staff are required to have appropriate experience
and any necessary training at the time of hiring. Documentation of trainings,
certifications and licensure shall be contained in personnel files. Registered and
certified SUD counselors shall adhere to all requirements in Title 9, Chapter 8.
33. CREDENTIALING/RECREDENTIALING
CONTRACTOR shall follow the COUNTY’s established credentialing and
re-credentialing process for all licensed and/or certified staff. Initial credentialing must
be completed prior to providing treatment services. Re-credentialing must be
completed every three (3) years.
34. MEDICAL DIRECTOR REQUIREMENTS
CONTRACTOR’s Medical Director must, prior to the delivery of services
under this Contract, be enrolled with DHCS under applicable state regulations,
screened in accordance with 42 CFR 455.450(a) as a “limited” categorical risk within a
year prior to serving as a Medical Director under this Agreement, and have a signed
Medicaid provider agreement with DHCS as required by 42 CFR 431.107.
Medical Directors shall receive a minimum of five (5) hours of continuing
medical education related to addiction medicine annually.
35. ASAM REQUIREMENTS
CONTRACTOR shall use COUNTY’s American Society of Addiction
Medicine (ASAM) criteria assessment and re-assessment tools to determine the
beneficiary’s level of care. CONTRACTOR shall ensure that assessment of services for
adolescents will follow the ASAM adolescent treatment criteria.
CONTRACTOR and CONTRACTOR’s staff shall comply with obtaining
ASAM Criteria training prior to providing services. CONTRACTOR shall ensure that, at
minimum, staff conducting assessments complete the two e-Training modules entitled
“ASAM Multidimensional Assessment” and “From Assessment to Service Planning and
Exhibit C
16
Revised 10/16/18
Level of Care”. The CIBHS ASAM webinars or in person trainings may be completed
in lieu of the e-Training modules. CONTRACTOR shall maintain records of ASAM
trainings in personnel files and will make these records available to COUNTY upon
request.
Residential care CONTRACTORs must meet the established ASAM
criteria for each level of residential care provided and receive an ASAM Designation
prior to providing DMC-ODS services.
36. MEDICAL NECESSITY
CONTRACTOR shall ensure that an initial medical necessity
determination, for an individual to receive a DMC-ODS benefit, is performed through a
face-to-face review or telehealth by a Medical Director or a LPHA. The Medical
Director or LPHA shall evaluate each beneficiary’s assessment and intake information,
if completed by a counselor, through a face-to-face review or telehealth with the
counselor to establish that a beneficiary meets medical necessity criteria. After
establishing a diagnosis and documenting the basis for diagnosis, the ASAM Criteria
shall be applied to determine placement into the level of assessed services.
CONTRACTOR shall ensure that all ADULT beneficiaries receive at a
diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM) Fifth
Edition for Substance-Related and Addictive Disorders. After establishing a diagnosis
and documenting the basis for diagnosis, the American Society of Addiction Medicine
(ASAM) Placement Criteria shall be applied by the diagnosing individual to for
placement into the correct level of care.
CONTRACTOR shall periodically as directed by COUNTY, and at a
minimum of every six (6) months, reassess for continued medical necessity of an
ongoing treatment. The reassessment determination must be documented by the
Medical Director, licensed physician or LPHA as clinically appropriate.
For Medical Necessity definition and Assessment and Reassessment
timeframes CONTRACTOR shall refer to the Provider Manual.
Individuals under age 21 are eligible to receive Medicaid services
pursuant to the Early Periodic Screening, Diagnostic and Treatment (EPSDT) mandate.
Under the EPSDT mandate, beneficiaries under the age 21 are eligible to receive all
appropriate and medically necessary services needed to correct and ameliorate health
conditions that are coverable under section 1905(a) Medicaid authority. Nothing in the
DMC-ODS shall override any EPSDT requirements. Medical necessity for an
adolescent individual (an individual under the age of 21) is determined using the
following criteria:
A. The adolescent individual may be assessed to be at-risk for
developing a SUD based on the following criteria:
Exhibit C
17
Revised 10/16/18
i. Substance use does NOT meet the minimum diagnosis
criteria per the DSM 5 ; and
ii. Reports of experimental or early-phase substance use,
associated biopsychosocial risk factors, and information
gathered from the full ASAM assessment and the At-Risk
Determination Tool indicate risk of developing an SUD.
B. The adolescent individual must meet the ASAM adolescent
treatment criteria.
37. MEDI-CAL ELIGIBILITY VERIFICATION
CONTRACTOR shall be responsible for verifying the Medi-Cal eligibility of
each beneficiary for each month of service prior to billing for DMC services for that
month. Medi-Cal eligibility verification should be performed prior to rendering service, in
accordance with and as described in the DHCS DMC Provider Billing Manual. Options
for verifying the eligibility of a Medi-Cal beneficiary are described in the DHCS DMC
Provider Billing Manual at the following web address and by this reference incorporated
herein. http://www.dhcs.ca.gov/formsandpubs/Documents/DMC_Billing_Manual_2017-
Final.pdf.
38. OTHER HEALTH COVERAGE BILLING REQUIREMENTS
In the event that a beneficiary has Other Health Coverage (OHC),
CONTRACTOR shall bill the OHC prior to billing DMC to receive either payment from
the OHC, or a notice of denial from the OHC indicating that either the recipient’s OHC
coverage has been exhausted or that the specific service is not a benefit of the OHC.
39. DMC REIMBURSEMENT RATE SETTING
CONTRACTOR shall submit financial and service data to COUNTY on an
annual basis in a format provide by, and by a deadline set by, COUNTY for
reimbursement rate setting purposes. COUNTY shall approve contractor-specific
reimbursement rates for each modality except NTPs. CONTRACTORs that do not
comply with the requirements of the rate setting process will be considered out of
compliance with contractual requirements and will not receive annual reimbursement
rates CONTRACTORs that are non-compliant are subject to contract termination.
Annual reimbursement rates for NTP services shall be set by DHCS
pursuant to the process set forth in W&I Code, Section 14021.51.
40. DMC CERTIFICATION AND ENROLLMENT
Prior to delivering SUD services CONTRACTOR shall obtain any licenses,
registrations, DMC certifications or approval to operate a SUD program or provide a
covered service in accordance with applicable laws and regulations. CONTRACTOR
shall continuously maintain any licenses, registrations, DMC certifications or approval
Exhibit C
18
Revised 10/16/18
to operate a SUD program or provide a covered service in accordance with applicable
laws and regulations for the duration of this Contract. CONTRACTOR and any
subcontractors shall comply with the following regulations and guidelines:
A. Title 21, CFR Part 1300, et seq., Title 42, CFR, Part 8;
B. Title 22, Sections 51490.1(a);
C. Exhibit A, Attachment I, Article III.PP – Requirements for Services;
D. Title 9, Division 4, Chapter 4, Subchapter 1, Sections 10000, et
seq.; and
E. Title 22, Division 3, Chapter 3, sections 51000 et. seq.
41. PERINATAL CERTIFICATION REQUIREMENTS
CONTRACTORs of perinatal DMC services shall be properly certified to
provide these services and comply with the applicable requirements below:
A. Perinatal services shall address treatment and recovery issues
specific to pregnant and postpartum women, such as relationships,
sexual and physical abuse, and development of parenting skills.
B. Perinatal services shall include:
1) Mother/child habilitative and rehabilitative services (i.e.,
development of parenting skills, training in child
development, which may include the provision of cooperative
child care pursuant to Health and Safety Code Section
1596.792);
2) Service access (i.e., provision of or arrangement for
transportation to and from medically necessary treatment);
3) Education to reduce harmful effects of alcohol and drugs on
the mother and fetus or the mother and infant; and
4) Coordination of ancillary services (i.e., assistance in
accessing and completing dental services, social services,
community services, educational/vocational training and
other services which are medically necessary to prevent risk
to fetus or infant).
C. Medical documentation that substantiates the beneficiary's
pregnancy and the last day of pregnancy shall be maintained in the
beneficiary file.
42. YOUTH TREATMENT GUIDELINES
CONTRACTOR shall follow the “Youth Treatment Guidelines,” available at
the DHCS web address at:
http://www.dhcs.ca.gov/individuals/Pages/youthSUDservices.aspx and by this reference
incorporated herein, in developing and implementing youth treatment programs funded
under this Agreement until such time new Youth Treatment Guidelines are established
Exhibit C
19
Revised 10/16/18
and adopted. No formal amendment of this contract is required for new guidelines to
apply.
43. CONTRACTOR CHANGE IN SERVICE OR LOCATION
CONTRACTOR shall ensure that any reduction of covered services or
relocations are not implemented until approval is issued by DHCS. CONTRACTOR
must submit a new DMC certification application to the DHCS Provider Enrollment
Division (PED). The DMC certification application shall be submitted to PED 60 days
prior to the desired effective date of the reduction of covered services or relocation.
CONTRACTOR shall notify COUNTY when its license, registration,
certification, or approval to operate a SUD program or provide a covered service is
revoked, suspended, modified, or not renewed by entities other than DHCS.
44. MEDICATION ASSISTED TREATMENT
CONTRACTORs that do not provide medication assisted treatment shall
have procedures for linkage/integration for beneficiaries requiring medication assisted
treatment. CONTRACTOR staff will regularly communicate with physicians of
beneficiaries who are prescribed these medications unless the beneficiary refuses to
consent to sign 42 CFR part 2 Compliant Releases of Information for this purpose.
45. EVIDENCE BASED PRACTICES (EBP)
CONTRACTOR shall implement Motivational Interviewing and at least two
EBPs prescribed by DHCS based on the timeline established by COUNTY as outlined
in the Provider Manual. The two additional required EBPs may be selected from the
following: Cognitive-Behavioral Therapy, Relapse Prevention, Trauma-Informed
Treatment and Psycho-Education. Three EBPs shall be utilized per service modality.
COUNTY and DHCS will monitor the implementation and regular training of EBPs to
staff during reviews. CONTRACTOR shall ensure that staff are internally monitored for
training, quality of delivery and fidelity of Evidence Based Practices.
46. COORDINATION AND CONTINUITY OF CARE WITH MANAGED CARE
PLANS
CONTRACTOR shall coordinate with the Managed Care Plans, Anthem
and CalVIVA Health, when appropriate, for comprehensive physical and behavioral
health screening and collaborative treatment planning. COUNTY shall maintain MOUs
with the managed care plans to facility beneficiary care coordination and will monitor
CONTRACTORs with regard to the effectiveness of physical health care coordination.
47. POSTSERVICE POSTPAYMENT AND POSTSERVICE PREPAYMENT
(PSPP)
DHCS shall conduct Postservice Postpayment and Postservice
Prepayment (PSPP) Utilization Reviews of contracted DMC providers to determine
Exhibit C
20
Revised 10/16/18
whether the DMC services were provided. DHCS shall issue the PSPP report to the
COUNTY with a copy to CONTRACTOR. CONTRACTOR shall ensure any deficiencies
are remediated and COUNTY shall attest the deficiencies have been remediated.
All CONTRACTOR shall submit a COUNTY-approved corrective action
plan (CAP) to DHCS within 60 days of the date of the PSPP report. CONTRACTOR(S)
that do not comply with the CAP submittal requirements or fail to implement the
approved CAP provisions within the designated timeline are subject to payment
withholding until compliance is determined.
48. DRUG SCREENING
Where drug screening by urinalysis is deemed medically appropriate,
CONTRACTOR shall establish procedures which protect against the falsification and/or
contamination of any urine sample and document urinalysis results in the beneficiary’s
file.
49. TREATMENT RECORDING REQUIREMENTS
CONTRACTOR shall comply with the requirements outlined in the
Intergovernmental Agreement, Exhibit A, Attachment I, Section PP, regarding
admission, assessment, beneficiary record, medical necessity and diagnosis, physical
examination, treatment plan, sign-in sheets, progress notes, continuing services, and
discharge.
50. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
(HIPAA) OF 1996
If any of the work performed under this Agreement is subject to the
HIPAA, CONTRACTOR shall perform the work in compliance with all applicable
provisions of HIPAA. As identified in Exhibit F of the State County Intergovernmental
Agreement, DHCS, COUNTY and CONTRACTOR shall cooperate to ensure mutual
agreement as to those transactions between them, to which this Provision applies.
Refer to Exhibit F for additional information.
A. Trading Partner Requirements
1) No Changes: CONTRACTOR hereby agrees that for the
personal health information (PHI), it shall not change any definition, data condition or
use of a data element or segment as proscribed in the federal Health and Human
Services Transaction Standard Regulation [45 CFR Part 162915(a)].
2) No Additions: CONTRACTOR hereby agrees that for PHI, it
shall not add any data elements or segments to the maximum data set as proscribed in
the HHS Transaction Standard Regulation [45CFR Part 162.915 (b)].
3) No Unauthorized Uses: CONTRACTOR hereby agrees that
for PHI, it shall not use any code or data elements that are marked ‘not used” in the in
the HHS Transactions Implementation specification or are not in the HHS Transaction
Standard’s implementation specification [45CFR Part 162.915 (c)].
Exhibit C
21
Revised 10/16/18
4) No Changes to Meaning or Intent: CONTRACTOR hereby
agrees that for PHI, it shall not change the meaning or intent of the HHS Transaction
Standard’s implementation specification [45CFR Part 162.915 (d)].
B. Concurrence for Test Modifications to HHS Transaction Standards
CONTRACTOR agrees and understands that there exists the possibility
that DHCS or others may request an extension from the uses of a standard in the HHS
Transaction Standards. If this occurs, CONTRACTOR agrees that it shall participate in
such test modifications.
C. Adequate Testing
CONTRACTOR is responsible to adequately test all business rules
appropriate to their types and specialties. If the CONTRACTOR is acting as a
clearinghouse for enrolled providers, CONTRACTOR has obligations to adequately test
all business rules appropriate to each and every provider type and specialty for which
they provide clearinghouse services.
D. Deficiencies
The CONTRACTOR agrees to cure transactions errors or deficiencies
identified by DHCS, and transactions errors or deficiencies identified by an enrolled
CONTRACTOR if the COUNTY is acting as a clearinghouse for that CONTRACTOR. If
the CONTRACTOR is a clearinghouse, the CONTRACTOR agrees to properly
communicate deficiencies and other pertinent information regarding electronic
transactions to enrolled CONTRACTORS for which they provide clearinghouse
services.
E. Code Set Retention
Both Parties understand and agree to keep open code sets being
processed or used in this Agreement for a least the current billing period or any appeal
period, whichever is longer.
F. Data Transmission Log
Both Parties shall establish and maintain a Data Transmission Log, which
shall record any and all data transmissions taking place between the Parties during the
term of this Agreement. Each Party shall take necessary and reasonable steps to
ensure that such Data Transmission Logs constitute a current, accurate, complete and
unaltered record of any and all Data Transmissions between the Parties, and shall be
retained by each Party for no less than twenty-four (24) months following the date of
the Data Transmission. The Data Transmission Log may be maintained on computer
media or other suitable means provided that, if necessary to do so, the information
contained in the Data Transmission Log may be retrieved in a timely manner and
presented in readable form.
Exhibit C
22
Revised 10/16/18
51. PARITY IN MENTAL HEALTH AND SUBSTANCE USE DISORDER
BENEFITS
A. General Parity Requirement
CONTRACTOR shall not impose any financial requirements,
Quantitative Treatment Limitations, or Non-Quantitative Treatment Limitations in any
classification of benefit (inpatient, outpatient, emergency care, or prescription drugs)
other than those limitations permitted and outlined in the State-County Contract.
CONTRACTOR shall not apply any financial requirement or
treatment limitation to substance use disorder services in any classification of benefit
that is more restrictive than the predominant financial requirement or treatment limitation
of that type applied to substantially all medical/surgical benefits in the same
classification of benefit furnished to beneficiaries (whether or not the benefits are
furnished by the CONTRACTOR). (42 CFR 438.910(b)(1))
CONTRACTOR shall provide substance use disorder services to
beneficiaries in every classification in which medical/surgical benefits are provided. (42
CFR 438.910(b)(2))
B. Quantitative Limitations
CONTRACTOR shall not apply any cumulative financial
requirement for substance use disorder services in a classification that accumulates
separately from any established for medical/surgical services in the same classification.
(42 CFR 438.910(c)(3))
C. Non-Quantitative Limitations
CONTRACTOR shall not impose a non-quantitative treatment
limitation for substance use disorder benefits in any classification unless, under the
policies and procedures of CONTRACTOR as written and in operation, any processes,
strategies, evidentiary standards, or other factors used in applying the non-quantitative
treatment limitation to substance use disorder benefits in the classification are
comparable to, and are applied no more stringently than, the processes, strategies,
evidentiary standards, or other factors used in applying the limitation for
medical/surgical benefits in the classification. (42 CFR §438.910(d))
CONTRACTOR shall use processes, strategies, evidentiary
standards, or other factors in determining access to out-of-network providers for
substance use disorder services that are comparable to, and applied no more
stringently than, the processes, strategies, evidentiary standards, or other factors in
determining access to out-of-network providers for medical/surgical benefits. (42 CFR
§438.910(d)(3))
Exhibit C
23
Revised 10/16/18
52. ACCESSIBILITY CONSIDERATIONS
CONTRACTOR shall ensure that their health programs or activities
provided through electronic and information technology are accessible to beneficiaries
with disabilities, unless doing so would result in undue financial and administrative
burdens or a fundamental alteration in the nature of the health programs or activities.
When undue financial and administrative burdens or a fundamental alteration exist,
CONTRACTOR shall provide information in a format other than an electronic format that
would not result in such undue financial and administrative burdens or a fundamental
alteration but would ensure, to the maximum extent possible, that beneficiaries with
disabilities receive the benefits or services of the health program or activity that are
provided through electronic and information technology.
CONTRACTOR shall make reasonable modifications to policies,
practices, or procedures when such modifications are necessary to avoid discrimination
on the basis of disability, unless CONTRACTOR can demonstrate that making the
modifications would fundamentally alter the nature of the health program or activity. For
the purposes of this section, the term ‘‘reasonable modifications’’ shall be interpreted in
a manner consistent with the term as set forth in the ADA Title II regulation at 28 CFR
35.130(b)(7).
Attachment A
Page 1 of 1
TRAFFICKING VICTIMS PROTECTION ACT OF 2000
CERTIFICATION
I, ______________________________________, as an authorized agent of (Print Name)
________________________________________, acknowledge the requirement to (Organization Name)
comply with the Trafficking Victims Protection Act of 2000 (TVPA), specifically Section
106(g), which authorizes the County of Fresno to terminate a contract, without penalty,
if this organization or its employees, or a subcontractor or its employees:
Engages in severe forms of trafficking in persons during the period of time that
the award is in effect;
Procures a commercial sex act during the period of time that the award in in
effect; or
Uses forced labor in the performance of the award or subawards under the
award.
I understand that the TVPA establishes human trafficking and related offenses
as federal crimes and attaches severe penalties to them. I will immediately inform the
County of Fresno, Department of Behavioral Health, Contracts Division – Substance
Use Disorder (SUD) Services immediately of any information received from any
source alleging a violation of the TVPA by either this organization or its employees, or
a subcontractor or its employees during the term of this contract.
I understand that this organization is obligated to ensure any subcontractors are
informed of the requirements of the TVPA and, if found in violation, will be immediately
terminated. I agree to submit this signed certification annually on behalf of the
organization acknowledging requirements under the TVPA and attesting that all
employees will receive annual TVPA training, and that documentation of training will
be placed in personnel files.
Signature:_____________________________ Date:______________________
Title:_________________________________
Attachment B
Page 1 of 1
UNLAWFUL USE OF DRUGS AND ALCOHOL
CERTIFICATION
I, ______________________________________, as an authorized agent of
(Print Name)
________________________________________, acknowledge the requirement to
(Organization Name)
comply with California HSC 11999-11999.3, which authorizes the County of Fresno to
terminate a contract, without penalty, if this organization or its employees, or a
subcontractor or its employees fail to ensure that:
The program contains a component that clearly explains in written materials that
there shall be no unlawful use of drugs or alcohol. No aspect of a drug- or alcohol-
related program shall include any message on the responsible use, if the use is
unlawful, of drugs or alcohol;
All aspects of a drug- or alcohol-related program are consistent with the “no
unlawful use” message, including, but not limited to, program standards,
curricula, materials, and teachings; and
The “no unlawful use” of drugs and alcohol message contained in drug- or
alcohol-related programs applies to the use of drugs and alcohol prohibited by
law.
I understand that the State of California enforces an Unlawful Use policy in which
there is zero tolerance for promoting the unlawful use of and drugs or alcohol in an AOD
treatment facility. If this organization fails to satisfy the guidelines adopted by the State
of California, the drug or alcohol program shall not receive state funds and their contract
with Fresno County will be terminated.
I understand that this organization is obligated to ensure any subcontractors are
informed of the requirements of HSC 11999-11999.3 and, if found in violation, will be
immediately terminated.
Signature:_____________________________ Date:______________________
Title:_________________________________
Attachment C
Page 1 of 1
3133 N Millbrook, Fresno, California 93703
FAX (559) 600-7673 www.co.fresno.ca.us
The County of Fresno is an Equal Employment Opportunity Employer
PRIVACY AND SECURITY AGREEMENT REGARDING AUTHORIZED ACCESS TO
CONFIDENTIAL PROTECTED HEALTH INFORMATION FOR FRESNO COUNTY DEPARTMENT
OF BEHAVIORAL HEALTH (DBH) EMPLOYEES AND/OR NON-DBH SUD SERVICES
WORKFORCE MEMBERS
OATH OF CONFIDENTIALITY
As a condition of obtaining access to any Protected Health Information (PHI) that is necessary to carry
out my function with DBH, I ___________________________, agree to not divulge any PHI to
unauthorized persons. Furthermore, I maintain that I will not publish or otherwise make public any
information regarding persons who receive Substance Use Disorder Services such that the persons who
receive or have received such services are identifiable.
Access to such data shall be limited to Fresno County DBH personnel, subcontractors, and
subcontractors’ personnel who require this information in the performance of their duties and have signed
an Oath of Confidentiality with DBH.
By signing this oath, I agree to uphold the security and confidentiality requirements outlined by the Medi-
Cal Privacy and Security Agreement signed by DBH, surveillance and safeguarding announcements
issued by DHCS, and other applicable terms and stipulations provided by the HIPAA doctrine as well as
other relevant state and federal regulations.
I hereby certify my understanding of the need to:
1. Exercise due care to preserve data integrity and confidentiality.
2. Treat passwords and user accounts as confidential information.
3. Take reasonable precautions to ensure the protection of PHI from unauthorized access.
4. Notify DHCS when there is a possible security violation including unauthorized access to PHI by
completing a “Privacy Incident Report” at:
http://www.dhcs.ca.gov/formsandpubs/laws/priv/Pages/DHCSBusinessAssociatesOnly.aspx and
return the completed form to: privacyofficer@dhcs.ca.gov.
I recognize that unauthorized release of confidential information may make me subject to civil and
criminal sanctions pursuant to the provisions of the Welfare and Institutions Code Section 14100.2,
Welfare and Institutions Code Section 5328 et seq. and the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). I further acknowledge that the unauthorized release of confidential
information as described in this document may result in disciplinary action up to and including
termination of any office of employment or contract.
Agency Name:
Signature:
____________________________________
Date:
____________________________________
Exhibit D
1 of 4 Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
1
rev 2017 Dec
DBH VISION:
Health and well‐being for our community.
DBH MISSION:
The Department of Behavioral Health is dedicated to supporting the wellness of individuals,
families and communities in Fresno County who are affected by, or are at risk of, mental illness
and/or substance use disorders through cultivation of strengths toward promoting recovery in
the least restrictive environment.
DBH GOALS:
Quadruple Aim
Deliver quality care
Maximize resources while focusing on efficiency
Provide an excellent care experience
Promote workforce well‐being
GUIDING PRINCIPLES OF CARE DELIVERY:
The DBH 11 principles of care delivery define and guide a system that strives for excellence in the
provision of behavioral health services where the values of wellness, resiliency, and recovery are
central to the development of programs, services, and workforce. The principles provide the
clinical framework that influences decision‐making on all aspects of care delivery including
program design and implementation, service delivery, training of the workforce, allocation of
resources, and measurement of outcomes.
1. Principle One ‐ Timely Access & Integrated Services
o Individuals and families are connected with services in a manner that is streamlined,
effective, and seamless
o Collaborative care coordination occurs across agencies, plans for care are integrated,
and whole person care considers all life domains such as health, education,
employment, housing, and spirituality
o Barriers to access and treatment are identified and addressed
o Excellent customer service ensures individuals and families are transitioned from one
point of care to another without disruption of care
Exhibit D
2 of 4 Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
2
rev 2017 Dec
2. Principle Two ‐ Strengths‐based
o Positive change occurs within the context of genuine trusting relationships
o Individuals, families, and communities are resourceful and resilient in the way they
solve problems
o Hope and optimism is created through identification of, and focus on, the unique
abilities of individuals and families
3. Principle Three ‐ Person‐driven and Family‐driven
o Self‐determination and self‐direction are the foundations for recovery
o Individuals and families optimize their autonomy and independence by leading the
process, including the identification of strengths, needs, and preferences
o Providers contribute clinical expertise, provide options, and support individuals and
families in informed decision making, developing goals and objectives, and identifying
pathways to recovery
o Individuals and families partner with their provider in determining the services and
supports that would be most effective and helpful and they exercise choice in the
services and supports they receive
4. Principle Four ‐ Inclusive of Natural Supports
o The person served identifies and defines family and other natural supports to be
included in care
o Individuals and families speak for themselves
o Natural support systems are vital to successful recovery and the maintaining of
ongoing wellness; these supports include personal associations and relationships
typically developed in the community that enhance a person’s quality of life
o Providers assist individuals and families in developing and utilizing natural supports.
5. Principle Five ‐ Clinical Significance and Evidence Based Practices (EBP)
o Services are effective, resulting in a noticeable change in daily life that is measurable.
o Clinical practice is informed by best available research evidence, best clinical
expertise, and client values and preferences
o Other clinically significant interventions such as innovative, promising, and emerging
practices are embraced
Exhibit D
3 of 4 Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
3
rev 2017 Dec
6. Principle Six ‐ Culturally Responsive
o Values, traditions, and beliefs specific to an individual’s or family’s culture(s) are
valued and referenced in the path of wellness, resilience, and recovery
o Services are culturally grounded, congruent, and personalized to reflect the unique
cultural experience of each individual and family
o Providers exhibit the highest level of cultural humility and sensitivity to the self‐
identified culture(s) of the person or family served in striving to achieve the greatest
competency in care delivery
7. Principle Seven ‐ Trauma‐informed and Trauma‐responsive
o The widespread impacts of all types of trauma are recognized and the various
potential paths for recovery from trauma are understood
o Signs and symptoms of trauma in individuals, families, staff, and others are recognized
and persons receive trauma‐informed responses
o Physical, psychological and emotional safety for individuals, families, and providers is
emphasized
8. Principle Eight ‐ Co‐occurring Capable
o Services are reflective of whole‐person care; providers understand the influence of
bio‐psycho‐social factors and the interactions between physical health, mental health,
and substance use disorders
o Treatment of substance use disorders and mental health disorders are integrated; a
provider or team may deliver treatment for mental health and substance use
disorders at the same time
9. Principle Nine ‐ Stages of Change, Motivation, and Harm Reduction
o Interventions are motivation‐based and adapted to the client’s stage of change
o Progression though stages of change are supported through positive working
relationships and alliances that are motivating
o Providers support individuals and families to develop strategies aimed at reducing
negative outcomes of substance misuse though a harm reduction approach
o Each individual defines their own recovery and recovers at their own pace when
provided with sufficient time and support
Exhibit D
4 of 4 Fresno County Department of Behavioral Health
Guiding Principles of Care Delivery
4
rev 2017 Dec
10. Principle Ten ‐ Continuous Quality Improvement and Outcomes‐Driven
o Individual and program outcomes are collected and evaluated for quality and efficacy
o Strategies are implemented to achieve a system of continuous quality improvement
and improved performance outcomes
o Providers participate in ongoing professional development activities needed for
proficiency in practice and implementation of treatment models
11. Principle Eleven ‐ Health and Wellness Promotion, Illness and Harm Prevention, and Stigma
Reduction
o The rights of all people are respected
o Behavioral health is recognized as integral to individual and community well‐being
o Promotion of health and wellness is interwoven throughout all aspects of DBH services
o Specific strategies to prevent illness and harm are implemented at the individual,
family, program, and community levels
o Stigma is actively reduced by promoting awareness, accountability, and positive
change in attitudes, beliefs, practices, and policies within all systems
o The vision of health and well‐being for our community is continually addressed
through collaborations between providers, individuals, families, and community
members
Fresno County DMC-ODS Approved Rates by Provider OPT IOT
Case
Management
Recovery
Services
Physician
Consultation
Withdrawal
Management
WM
Room/Board
Residential
3.1
Residential
3.1
Room/Board
Residential
3.5
Residential 3.5
Room/Board MAT
APPROVED MAXIMUM UOS RATE 36.79 22.71 35.00 33.30 153.60 129.36 - 180.44 - 178.62 - 153.60
COUNTY APPROVED PROVIDER RATES:
Central California Recovery 31.69 22.18 27.42 31.96
Fresno New Connections 28.14 22.18 21.50 23.99
Kings View 29.45 27.03 30.02
Mental Health Systems 36.79 22.18 33.67 32.74 157.11 68.51 157.11 68.51
Panacea 30.24 22.18 27.28 16.83
Promesa 33.68 28.73 23.86
Turning Point 31.15 29.73 16.42 111.05 72.35 111.05 78.61
Transitions Children's Services 36.23 26.38
WestCare 32.13 22.18 35.00 32.13 153.60 100.00 37.74 180.44 153.60
WestCare - Perinatal 37.74 178.62 37.03
WestCare - Mens 35.35 133.51 35.15
WestCare - Womens 36.81 150.92 36.81
Exhibit E
11/13/2018
Exhibit E
Department of Health Care Services
Substance Use Disorders - Program, Prevention and Fiscal
Division Drug Medi-Cal (DMC) Rates for Fiscal Year 2018-19
Non-Perinatal DMC
Description Unit of Service (UOS) FY 2018-19 UOS
Rate**
Narcotic Treatment Program (NTP) -
Methadone Daily $13.54
NTP - Individual Counseling One 10-minute Increment $15.88
NTP - Group Counseling One 10-minute Increment $3.43
Intensive Outpatient Treatment Face-to-Face Visit $58.53
Naltrexone (*) Face-to-Face Visit $19.06
Residential - for EPSDT Beneficiaries Daily $90.14
Outpatient Drug Free (ODF) Individual
Counseling
Face-to-Face Visit (Per
Person) $79.44
ODF Group Counseling Face-to-Face Visit (Per
Person) $30.89
Perinatal DMC
Description Unit of Service (UOS) FY 2018-19 UOS
Rate**
NTP - Methadone Daily $14.58
NTP - Individual Counseling One 10-minute Increment $16.39
NTP - Group Counseling One 10-minute Increment $4.28
Intensive Outpatient Treatment Face-to-Face Visit $87.21
Perinatal Residential Daily $90.14
ODF Individual Counseling Face-to-Face Visit (Per
Person) $81.93
ODF Group Counseling Face-to-Face Visit (Per
Person) $38.56
* From FY 2002-03 through FY 2008-09, Naltrexone was frozen at the $21.19 (FY 1999 -2000)
approved rate. Counties and service providers have not provided, submitted claims, nor reported
cost for this service since FY 1997-98. For FY 2009-10, the $21.19 frozen rate was reduced by
10 percent to $19.07. Excluding county administration from the cost data used to produce the
$21.19 frozen approved rate decreased it to $19.06. Drug Medi-Cal used $19.06 as the FY 2018-
19 developed rate.
Exhibit E
** FY 2009-2010 rates were adjusted by a 19.4 percent cumulative growth in the Implicit Price
Deflator (IDP), in accordance with Welfare & Institutions Code Section 14021.9(b). The change
from year to year are as follows: 0% for FY 2009-10, 3.2% for
FY 2010-11, 2.5% for FY 2011-12, 1.9% for FY 2012-13, 2.1% for FY 2013-14, 1.2% for FY
2014-15, 0.4% for FY 2015-16, 1.9% for FY 2016-17, 2.4% for FY 2017-18 and 2.3% for FY
2018-19.
Exhibit E
Department of Health Care Services
Substance Use Disorders - Program, Policy and Fiscal Division
Drug Medi-Cal Rates for Fiscal Year 2018-19
Additional Medication Assisted Treatments Available in Waiver Opt-In
Counties, Narcotic Treatment Programs
FY 2018-19 FY 2018-19
Description Unit of Service (UOS) UOS Rate UOS Rate
Regular DMC Perinatal DMC
Narcotic Treatment Program (NTP)
Buprenorphine - Mono 1 Daily $16.91 $20.15
NTP - Buprenorphine-Naloxone
Combination Product 2 Daily $20.10 $23.34
NTP – Disulfiram 3 Daily $7.36 $7.59
NTP - Naloxone: 2-pack Nasal Spray4 Dispensed according to need $144.60 $144.60
1 Buprenorphine-Mono: Average daily dose of 16 milligrams, sublingual tablets
2 Buprenorphine-Naloxone Combination
3 Disulfiram: Average daily dose between 250 and 500 milligrams
4 Naloxone: One dose equal to 4 milligrams per 0.1 milliliter
Exhibit F Page 1 of 1 ELECTRONIC HEALTH RECORD SOFTWARE CHARGES CONTRACTOR(S) understand that COUNTY utilizes NetSmart’s Avatar for its Electronic Health Records Management. CONTRACTOR(S) agree to reimburse COUNTY for all user license fees for accessing NetSmart’s Avatar, as set forth below. Description FY 2018-19 FY 2019-20 FY 2020-21 FY 2021-22 FY 2022-23 General Users Avatar Named User Hosting (per active user per month; every Avatar “active” log on ID is a named user) $37.00 $37.00 $37.00 $37.00 $37.00 Avatar Named User Maintenance* (per active user per month) $14.00 $14.00 $14.00 $14.00 $14.00 Cloud Hosting- Perceptive Disaster Recovery (per active user per month) $4.66 $4.66 $4.66 $4.66 $4.66 eRx Users Full Suite Prescriber (per active user per month; applicable to an active Prescriber user) $104.00 $104.00 $104.00 $104.00 $104.00 ePrescribing Controlled Substances Tokens (per active user per month; applicable to an active Prescriber user of Controlled Substances) $8.00 $8.00 $8.00 $8.00 $8.00 Non-Prescribing User (per active user per month; applicable to an active Non-Prescriber user) $13.00 $13.00 $13.00 $13.00 $13.00 Reaching Recovery Users Reaching Recovery (per adult client/person served per year; applicable to adult treatment programs except contracted triage/CI, CSU or PHF) $10.00 $10.00 $10.00 $10.00 $10.00 ProviderConnect Users Individual Subscription1 (per user per month; applicable to provider-user whose claims are reviewed and posted by Managed Care) $41.25 $41.25 $41.25 $41.25 $41.25 Should CONTRACTOR(S) choose not to utilize NetSmart’s Avatar for its Electronic Health Records management, CONTRACTOR(S) will be responsible for obtaining its own system for Electronic Health Records management. ______________________________________________________________________________________________________________________ *Annual Maintenance increases by 3% each FY on July 1st. 1Includes 100 faxed pages per month. An additional fee of $0.20 per faxed page will apply thereafter.
Exhibit G
Page 1 of 2
SELF‐DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”),
members of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must
disclose any self‐dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self‐dealing transaction is defined below:
“A self‐dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member’s name, job title (if applicable), and date this disclosure is being made.
(2) Enter the board member’s company/agency name and address.
(3) Describe in detail the nature of the self‐dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the transaction; and
b. The nature of the material financial interest in the Corporation’s transaction that the
board member has.
(4) Describe in detail why the self‐dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self‐dealing transaction
described in Sections (3) and (4).
Exhibit G
Page 2 of 2
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self‐dealing transaction you are a party to):
(4) Explain why this self‐dealing transaction is consistent with the requirements of Corporations Code 5233 (a):
(5) Authorized Signature
Signature: Date:
Exhibit H
Page 1 of 3
DISCLOSURE – CRIMINAL HISTORY & CIVIL ACTIONS:
In their proposal, the bidder is required to disclose if any of the following conditions apply to
them, their owners, officers, corporate managers and partners (hereinafter collectively
referred to as “Bidder”):
Within the three-year period preceding the proposal, they have been convicted of, or
had a civil judgment rendered against them for:
o fraud or a criminal offense in connection with obtaining, attempting to obtain, or
performing a public (federal, state, or local) transaction or contract under a
public transaction;
o violation of a federal or state antitrust statute;
o embezzlement, theft, forgery, bribery, falsification, or destruction of records; or
o false statements or receipt of stolen property
Within a three-year period preceding their proposal, they have had a public transaction
(federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate a Bidder from
consideration. The information will be considered as part of the determination of whether to
award the contract and any additional information or explanation that a Bidder elects to submit
with the disclosed information will be considered. If it is later determined that the Bidder failed
to disclose required information, any contract awarded to such Bidder may be immediately
voided and terminated for material failure to comply with the terms and conditions of the
award.
Any Bidder who is awarded a contract must sign an appropriate Certification Regarding
Debarment, Suspension, and Other Responsibility Matters, pages 2 and 3 of this Exhibit,
Additionally, the Bidder awarded the contract must immediately advise the County in writing if,
during the term of the agreement: (1) Bidder becomes suspended, debarred, excluded or
ineligible for participation in federal or state funded programs or from receiving federal funds
as listed in the excluded parties list system (http://www/epls/gov); or (2) any of the above
listed conditions become applicable to Bidder. The Bidder will indemnify, defend and hold the
County harmless for any loss or damage resulting from a conviction, debarment, exclusion,
ineligibility or other matter listed in the signed Certification Regarding Debarment,
Suspension, and Other Responsibility Matters.
Exhibit H
Page 2 of 3
CERTIFICATION REGARDING DEBARMENT,
SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED
TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is providing
the certification set out below.
2. The inability of a person to provide the certification required below will not necessarily
result in denial of participation in this covered transaction. The prospective participant shall
submit an explanation of why it cannot provide the certification set out below. The
certification or explanation will be considered in connection with the department or
agency's determination whether to enter into this transaction. However, failure of the
prospective primary participant to furnish a certification or an explanation shall disqualify
such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which reliance was
placed when the department or agency determined to enter into this transaction. If it is
later determined that the prospective primary participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal Government, the
department or agency may terminate this transaction for cause or default.
4. The prospective primary participant shall provide immediate written notice to the
department or agency to which this proposal is submitted if at any time the prospective
primary participant learns that its certification was erroneous when submitted or has
become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant, person,
primary covered transaction, principal, proposal, and voluntarily excluded, as used in this
clause, have the meanings set out in the Definitions and Coverage sections of the rules
implementing Executive Order 12549. You may contact the department or agency to which
this proposal is being submitted for assistance in obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment of a system
of records in order to render in good faith the certification required by this clause. The
knowledge and information of a participant is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.
Exhibit H
Page 3 of 3
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it,
its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of or had a
civil judgment rendered against them for commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State
or local) transaction or contract under a public transaction; violation of Federal or State
antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
(c) Have not within a three-year period preceding this application/proposal had one or
more public transactions (Federal, State or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or Company)
ELECTRONIC SIGNATURE AGREEMENT
Exhibit I
This Agreement governs the rights, duties, and responsibilities of _____________
County in the use of an electronic signature in __________________ County. The
undersigned (I) understands that this Agreement describes my obligations to protect my
electronic signature, and to notify appropriate authorities if it is stolen, lost,
compromised, unaccounted for, or destroyed. I agree to the following terms and
conditions:
I agree that my electronic signature will be valid for one year from date of issuance or
earlier if it is revoked or terminated per the terms of this agreement. I will be notified
and given the opportunity to renew my electronic signature each year prior to its
expiration. The terms of this Agreement shall apply to each such renewal.
I will use my electronic signature to establish my identity and sign electronic documents
and forms. I am solely responsible for protecting my electronic signature. If I suspect or
discover that my electronic signature has been stolen, lost, used by an unauthorized party,
or otherwise compromised, then I will immediately notify the County Mental Health
Director or his/her designee and request that my electronic signature be revoked. I will
then immediately cease all use of my electronic signature. I agree to keep my electronic
signature secret and secure by taking reasonable security measures to prevent it from
being lost, modified or otherwise compromised, and to prevent unauthorized disclosure
of, access to, or use of it or of any media on which information about it is stored.
I will immediately request that my electronic signature be revoked if I discover or suspect
that it has been or is in danger of being lost, disclosed, compromised or subjected to
unauthorized use in any way. I understand that I may also request revocation at any time
for any other reason.
If I have requested that my electronic signature be revoked, or I am notified that someone
has requested that my electronic signature be suspended or revoked, and I suspect or
discover that it has been or may be compromised or subjected to unauthorized use in any
way, I will immediately cease using my electronic signature. I will also immediately
cease using my electronic signature upon termination of employment or termination of
this Agreement.
I further agree that, for the purposes of authorizing and authenticating electronic health
records, my electronic signature has the full force and effect of a signature affixed by
hand to a paper document.
Requestor
Signature Date
Requestor
Printed Name
Approver
Signature Date
Title
FRESNO COUNTY BEHAVIORAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws, regulations, rules
and guidelines that apply to the provision and payment of behavioral health services. Behavioral health
contractors and the manner in which they conduct themselves are a vital part of this commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor, contractor’s employees and subcontractors shall comply. Contractor shall require its
employees and subcontractors to attend a compliance training that will be provided by Fresno County
DBH. After completion of this training, each contractor, contractor's employee and subcontractor must
sign the Behavioral Health Compliance Training Acknowledgment and Agreement form and return this
form to the Compliance officer or designee.
Contractor and its employees and subcontractor shall:
1.Comply with all applicable laws, regulations, rules or guidelines when providing and billing for
behavioral health services.
2.Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their
professional dealing related to their contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County.
3.Treat County employees, beneficiaries, and other behavioral health contractors fairly and with
respect.
4.NOT engage in any activity in violation of the County's Compliance Program, nor engage in any
other conduct which violates any applicable law, regulation, rule or guideline
5.Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6.Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement of
any kind are submitted.
7.Bill only for eligible services actually rendered and fully documented. Use billing codes that
accurately describe the services provided.
8.Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9.Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct
and Ethics by County employees or other behavioral health contractors, or report any activity
that they believe may violate the standards of the Compliance Program, or any other applicable
Exhibit J
Revised 09/20/18 1
law, regulation, rule or guideline. Fresno County prohibits retaliation against any person making
a report. Any person engaging in any form of retaliation will be subject to disciplinary or other
appropriate action by the County. Contractor may report anonymously.
10.Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11.Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
12. Immediately contact the DBH Business Office inbox using the
DBHADPBusinessOffice@fresnocountyca.gov and your assigned DBH analyst and report any
overpayment.
Exhibit J
Revised 09/20/18 2
FRESNO COUNTY BEHAVIORAL HEALTH PLAN
COMPLIANCE PROGRAM
2018 New Hire Behavioral Health Compliance Training
Acknowledgment and Agreement
I hereby acknowledge that I have completed the Mandatory New Hire Behavioral Health Compliance
Training which provided information on Fresno County’s Behavioral Health Compliance Program and that
I understand the contents thereof. I further acknowledge that I have received, read and understand
Fresno County’s Compliance Program policy titled “Prevention, Detection, and Correction of Fraud,
Waste and Abuse”. I agree to abide by the Code of Conduct, and all Compliance Program requirements
as they apply to my responsibilities as a County employee, contractor/subcontractor, volunteer or
student.
I understand and accept my responsibilities under this Acknowledgment and Agreement and understand
that any violation of the Code of Conduct or the Compliance Program is a violation of County policy and
may also be a violation of applicable laws, regulations, rules or guidelines. I further understand that
violation of these policies can result in disciplinary action, up to and including termination of my
employment or contractual agreement with the County.
County Employees Only – Complete this Section
Full Name (printed): ________________________________________________
Job Title: _________________________________________________________
Discipline (for licensed staff only): [ ] Psychiatrist [ ] Psychologist [ ] Substance Abuse Specialist
[ ] LCSW [ ] LMFT [ ] NP [ ] RN [ ] LVN [ ] LPT
DBH Department: [ ] Adult MH [ ] Children MH [ ] Finance Division [ ] Managed Care
[ ] Administration [ ] Substance Abuse Services [ ] Other:
___________________
Cost Center#________ Program Name: _________________________________
Supervisor Name: __________________________________________
Employee Signature: _________________________________________Date:___/___/____
Phone: _______________ _
Contractors/Contractor Staff, Volunteers, Students only – Complete this Section
Agency Name (If applicable):______________________________________________
Full Name (Printed):____________________________________________________
Discipline (Indicate below if applicable):
Licensed: [ ] Psychiatrist [ ] Psychologist [ ] LCSW [ ] LMFT [ ] NP [ ] RN [ ] LVN [ ] LPT
[ ] MD
Unlicensed: [ ] Psychologist [ ] ACSW [ ] AMFT [ ] APCC [ ] Certified AOD Counselor
[ ] Registered AOD Counselor Other______________________________________________
Job Title (If different from Discipline): ___________________________________________
Signature: _________________________________________________Date:____/____/____
Phone: ________________________ E-mail:________________________________________
Mail this completed form with your original signature (not a copy) to:
Elizabeth Vasquez, Behavioral Health Compliance Officer Stop #100-Heritage Center
3133 N. Millbrook, Rm. 171, Fresno, CA 93703
2014 Annual Ack Rev: 1/8/14, 12/22/16, 1/8/18, 6/7/18
Exhibit J
Revised 09/20/18 3
Exhibit K
Page 1 of 2
CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES
CONTRACTOR shall adhere to and develop written procedures in accordance with the below standards
adapted from the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in
Health Care:
Culturally Competent Care:
1. Organizations must ensure that beneficiaries receive from all staff members effective,
understandable, and respectful care that is provided in a manner compatible with
their cultural health beliefs and practices and preferred language.
2. Organizations must implement strategies to recruit, retain, and promote at all levels
of the organization a diverse staff and leadership that are representative of the
demographic characteristics of the service area.
3. Organizations must ensure that staff at all levels and across all disciplines receive
ongoing education and training in culturally and linguistically appropriate service
delivery.
Language Access Services:
4. Organizations must offer and provide language assistance services, including bilingual
staff and interpreter services, at no cost to beneficiaries with limited English
proficiency at all points of contact, in a timely manner during all hours of operation.
5. Organizations must provide to beneficiaries in their preferred language both verbal
offers and written notices informing them of their right to receive language assistance
services.
6. Organizations must assure the competence of language assistance provided to limited
English proficient beneficiaries by interpreters and bilingual staff. Family and friends
should not be used to provide interpretation services (except on the request of the
beneficiary).
7. Organizations must make available easily understood beneficiary‐related materials
and post signage in the languages of the commonly encountered groups and/or
groups represented in the service area.
Organizational Supports:
8. Organizations must develop, implement, and promote a written strategic plan that
outlines clear goals, policies, operational plans, and management
accountability/oversight mechanisms to provide culturally and linguistically
appropriate services.
Exhibit K
Page 2 of 2
9. Organizations must conduct initial and ongoing organizational self‐assessments of
CLAS related activities and are encouraged to integrate cultural and linguistic
competence‐related measures into their internal audits, performance improvement
programs, beneficiary satisfaction Assessments, and Outcomes‐Based Evaluations.
10. Organizations must ensure that data on the individual beneficiary’s race, ethnicity,
and spoken and written language are collected in program records, integrated into the
organizations management information systems, and periodically updated.
11. Organizations must maintain a current demographic, cultural, and epidemiological
profile of the community as well as a needs assessment to accurately plan for and
implement services that respond to the cultural and linguistic characteristics of the
service area.
12. Organizations must develop participatory, collaborative partnerships with
communities and utilize a variety of formal and informal mechanisms to facilitate
community and beneficiary involvement in designing and implementing CLAS‐related
activities.
13. Organizations must ensure that conflict and grievance resolution processes are
culturally and linguistically sensitive and capable of identifying, preventing, and
resolving cross‐cultural conflicts or complaints by beneficiaries.
14. Organizations must regularly make available to the public information about their
progress and successful innovations in implementing these standards and to provide
public notice in their communities about the availability of this information.
15. Organizations must ensure communication regarding the organization’s progress in
implementing and sustaining CLAS to all stakeholders, constituents, and general
public.
CONTRACTOR shall develop written procedures in accordance with the above standards. The
provisions of this Agreement are not intended to abrogate any provisions of law or regulation existing
or enacted during the term of this Agreement.
Exhibit L
Page 1 of 1
NOTICE OF CHILD ABUSE REPORTING LAW
The undersigned hereby acknowledges that Penal Code section 11166 and the
contractual obligations between County of Fresno (COUNTY) and PROVIDER(S)
related to provision of alcohol and drug abuse treatment services for Fresno County
residents, require that the undersigned report all known or suspected child abuse or
neglect to one or more of the agencies set forth in Penal Code (P.C.) section (§) 11165.9.
For purposes of the undersigned’s child abuse reporting requirements, “child
abuse or neglect” includes physical injury inflicted by other than accidental means upon a
child by another person, sexual abuse as defined in P.C. §11165.1, neglect as defined in
P.C. §11165.2, willful cruelty or unjustifiable punishment as defined in P.C. §11165.3,
and unlawful corporal punishment or injury as defined in P.C. §11165.4.
A child abuse report shall be made whenever the undersigned, in his or her
professional capacity or within the scope of his or her employment, has knowledge of or
observes a child whom the undersigned knows or reasonably suspects has been the victim
of child abuse or neglect. (P.C §11166.) The child abuse report shall be made to any
police department or sheriff’s department (not including a school district police or
security department), or to any county welfare department, including Fresno County
Department of Children and Family Services’ 24 Hour CARELINE. (See PC §11165.9.)
For purposes of child abuse reporting, a “reasonable suspicion” means that it is
objectively reasonable for a person to entertain a suspicion, based upon facts that could
cause a reasonable person in a like position, drawing, when appropriate, on his or her
training and experience, to suspect child abuse or neglect. The pregnancy of a child does
not, in and of itself, constitute a basis for reasonable suspicion of sexual abuse. (P.C.
§11166(a)(1).)
Substantial penalties may be imposed for failure to comply with these child abuse
reporting requirements.
Further information and a copy of the law may be obtained from the department
head or designee.
I have read and understand the above statement and agree to comply with the
child abuse reporting requirements.
__________________________________ ________________________
SIGNATURE DATE
0980fadx
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of Entity D/B/A
Address (number, street) City State ZIP Code
CLIA Number Taxpayer ID Number (EIN) / Social Security Number Telephone Number
( )
II. Answer the following questions by checking “Yes” or “No.” If any of the questions are answered “Yes,” list all names
and addresses (primary, every business location, and P.O. Box address) of individuals or corporations under “Remarks” on
page 2. Identify each item number to be continued.
A. Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
YES NO
by Titles XVIII, XIX, or XX? ......................................................................................................................... ❒ ❒
B. Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX? ...................................................................................... ❒ ❒
C. Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution’s, organization’s, or
agency’s fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ........... ❒ ❒
III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses (primary, every business location, and P.O. Box address) under “Remarks” on page 2. If more than
one individual is reported and any of these persons are related to each other, this must be reported under “Remarks.”
NAME DOB ADDRESS EIN
B. Type of entity: ❒ Sole proprietorship ❒Partnership ❒Corporation
❒Unincorporated Associations ❒Other (specify)
C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under “Remarks.”
D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers. .......................................................................................................... ❒ ❒
NAME DOB ADDRESS PROVIDER
Exhibit M
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YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒
If yes, when?
C.Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... ❒ ❒
VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B.If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date
Remarks
Exhibit M
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INSTRUCTIONS FOR COMPLETING DISCLOSURE OF CONTROL AND INTEREST STATEMENT
Please answer all questions as of the current date. If the yes block for any item is checked, list requested additional information under the
Remarks Section on page 2, referencing the item number to be continued. If additional space is needed use an attached sheet.
DETAILED INSTRUCTIONS
These instructions are designed to clarify certain questions on the form. Instructions are listed in question order for easy reference. No
instructions have been given for questions considered self-explanatory.
IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL INFORMATION BE
CURRENT.
Item I - Under “Identifying Information” specify in what capacity the entity is doing business as (DBA) (e.g. name of trade or corporation).
Item II - Self-explanatory
Item III - List the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or
in combination amounting to an ownership interest of 5 percent or more in the disclosing entity.
Direct ownership interest - is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity. A
disclosing entity is defined as a Medicare provider or supplier, or other entity that furnishes services or arranges for furnishing services under
Medicaid or the Maternal and Child Health program, or health related services under the social services program.
Indirect ownership interest - is defined as ownership interest in an entity that has direct or hospital-based home health agencies, are
not indirect ownership interest in the disclosing entity. The amount of indirect ownership in the disclosing entity that is held by any
other entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership interest must
beds in the facility now and the previous be reported if it equates to an ownership interest of 5 percent or more in the disclosing
entity. Example: if A owns 10 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing entity, A's
interest equates to an 8 percent indirect ownership and must be reported.
Controlling interest - is defined as the operational direction or management of disclosing entity which may be maintained by any or all of
the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity (i.e., joint venture
agreement, unincorporated business status) of the disclosing entity; the ability or authority to nominate or name members of the Board of
Directors or Trustees of the disclosing entity; the ability or authority, expressed or reserved, to amend or change the by-laws, constitution,
or other operating or management direction of the disclosing entity; the right to control any or all of the assets or other property of the
disclosing entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved, to control the sale of any or all of
the assets, to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity or to arrange for the sale or transfer of
the disclosing entity to new ownership or control.
Item IV-VII - (Changes in Provider Status) For Items IV-VII, if the yes box is checked, list additional information requested under
Remarks. Clearly identify which item is being continued.
Change in provider status - is defined as any change in management control. Examples of such changes would include; a change in Medical
or Nursing Director, a new Administrator, contracting the operation of the facility to a management corporation, a change in the composition of
the owning partnership which under applicable State law is not considered a change in ownership, or the hiring or dismissing of any employees
with 5 percent or more financial interest in the facility or in an owning corporation, or any change of ownership.
Item IV - (A & B) If there has been a change in ownership within the last year or if you anticipate a change, indicate the date in the
appropriate space.
Item V - If the answer is yes, list name of the management firm and employer identification number (EIN), or the name of the leasing
organization. A management company is defined as any organization that operates and manages a business on behalf of the owner of that
business, with the owner retaining ultimate legal responsibility for operation of the facility.
Item VI - If the answer is yes, identify which has changed (Administrator, Medical Director, or Director of Nursing) and the date the change
was made. Be sure to include name of the new Administrator, Director of Nursing or Medical Director, as appropriate.
Item VII - A chain affiliate is any free-standing health care facility that is either owned, controlled, or operated under lease or contract by an
organization consisting of two or more free-standing health care facilities organized within or across State lines which is under the ownership or
through any other device, control and direction of a common party. Chain affiliates include such facilities whether public, private, charitable or
proprietary. They also include subsidiary organizations and holding corporations. Provider-based facilities, such as hospital-based home health
agencies, are not considered to be chain affiliates.
Exhibit M
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