HomeMy WebLinkAboutOn file with Clerk - Amendment 1 to A-22-452 with DHCS 22-20101-A1.pdf STATE OF CALIFORNIA-DEPARTMENT OF GENERAL SERVICES SCO ID'4260-2220101-A 1
STANDARD AGREEMENT-AMENDMENT
STD 213A(Rev.4/2020) AGREEMENT NUMBER AMENDMENT NUMBER Purchasing Authority Number
® CHECK HERE IF ADDITIONAL PAGES ARE ATTACHED 160 PAGES 22-201 01 Al
1.This Agreement is entered into between the Contracting Agency and the Contractor named below:
CONTRACTING AGENCY NAME
Department of Health Care Services
CONTRACTOR NAME
County of Fresno
2.The term of this Agreement is:
START DATE
July 1,2022
THROUGH END DATE
June 30,2027
3.The maximum amount of this Agreement after this Amendment is:
$0.00(Zero Dollars and Zero Cents)
4.The parties mutually agree to this amendment as follows.All actions noted below are by this reference made a part of the Agreement and
incorporated herein:
I.The effective date of this amendment is the date approved by DHCS.
II.Purpose of Amendment:This amendment modifies the terms and conditions of the Agreement.
III.Certain changes made in this amendment are shown as:Text additions are displayed in bold and underline.Text deletions are displayed as strike
through text.
(Continued on Next Page)
All other terms and conditions shall remain the some.
IN WITNESS WHEREOF,THIS AGREEMENT HAS BEEN EXECUTED BY THE PARTIES HERETO.
CONTRACTOR
CONTRACTOR NAME(if other than an individual,state whether a corporation,partnership,etc.)
County of Fresno
CONTRACTOR BUSINESS ADDRESS CITY STATE ZIP
1925 East Dakota Avenue Fresno Ca 93726
PRINTED NAME OF PERSON SIGNING TITLE
Nathan Magsig Chairman of the Board of Supervisors
CONTRACTOR AUTHORIZED SIGNATURE DATE SIGNED
Page 1 of 2
STATE OF CALIFORNIA-DEPARTMENT OF GENERAL SERVICES SCO ID'4260-2220101-All
STANDARD AGREEMENT-AMENDMENT
STD 213A(Rev.4/2020) AGREEMENT NUMBER AMENDMENT NUMBER Purchasing Authority Number
® CHECK HERE IF ADDITIONAL PAGES ARE ATTACHED 160 PAGES 22-20101 Al
STATE OF CALIFORNIA
CONTRACTING AGENCY NAME
Department of Health Care Services
CONTRACTING AGENCY ADDRESS CITY STATE ZIP
1501 Capitol Avenue,NIS 4200 Sacramento CA 95814
PRINTED NAME OF PERSON SIGNING TITLE
CONTRACTING AGENCY AUTHORIZED SIGNATURE DATE SIGNED
CALIFORNIA DEPARTMENT OF GENERAL SERVICES APPROVAL EXEMPTION(If Applicable)
WIC 14703
Page 2 of 2
County of Fresno
22-20101 Al
Page 3 of 3
STD 213A Continuation Page
IV. Paragraph 4 (incorporated exhibits) on the face of the original STD 213 is
amended to add the following new exhibit:
Exhibit A— Scope of Work ( 2 Pages)
Exhibit A— Attachment 1 - Organization and Administration (6 Pages)
Exhibit A— Attachment 2 - Scope of Services (11 Pages)
Exhibit A— Attachment 3 - Financial Requirements (6 Pages)
Exhibit A— Attachment 4 - Management Information Systems (4 Pages)
Exhibit A— Attachment 5 - Quality Improvement System (7 pages)
Exhibit A— Attachment 6 - Utilization Management Program (3 Pages)
Exhibit A— Attachment 7 - Access and Availability of Services (5 pages)
Exhibit A— Attachment 8 - Provider Network (13 Pages)
Exhibit A— Attachment 9 - Documentation Requirements (1 Page)
Exhibit A— Attachment 10 - Coordination and Continuity of Care (4 Pages)
Exhibit A— Attachment 11 - Information Requirements (16 Pages)
Exhibit A— Attachment 12 - Member Problem Resolution (25 Pages)
Exhibit A— Attachment 13 - Program Integrity (7 Pages)
Exhibit A— Attachment 14 - Reporting Requirements (3 Pages)
Exhibit A— Attachment 15 - Peer Support Services (2 Pages)
Exhibit B - Budget Details and Payment Provision (7 Pages)
Exhibit E — Additional Provisions (17 Pages)
Exhibit E — Attachment 1- Definitions (9 Pages)
Exhibit E — Attachment 2 - Service Definitions (11 Pages)
Exhibit A, Exhibit A— Attachments 1-15, Exhibit B, Exhibit E, Exhibit E — Attachment
1 & 2, shall hereinafter be replaced with the above mentioned revised Exhibits
included in this amendment Al.
V. All other terms and conditions shall remain the same.
County of Fresno
22-20101 Al
Page 1 of 2
Exhibit A
SCOPE OF WORK
1. Service Overview
The Contractor agrees to provide to the California Department of Health Care
Services (hereinafter referred to as DHCS, The Department, or the state
DHCS) the services described herein.
The Contractor will provide or arrange for the provision of specialty mental health
services to eligible Medi-Cal members beRefiGiari of Fresno County within the
scope of services defined in this contract.
2. Service Location
The services shall be performed at all contracting and participating facilities of
the Contractor.
3. Service Hours
The services shall be provided on a 24-hour, seven (7) days a week basis.
4. Project Representatives
A. The project representatives during the term of this contract will be:
Department of Health Care Services County of Fresno
Teresa Castillo Susan Holt, Director of
Telephone: (916) 713-8545 Behavioral Health
Email: Teresa.CastiIlo(a).dhcs.ca.gov Telephone: 559-600-9180
Fax: 559-600-7905
Email:
sholt@fresnocountyca.gov
B. Direct all inquiries to:
Department of Health Care Services County of Fresno
Medi-Cal Behavioral Health Attention: Joseph Rangel
Division/Program Policy Section 1925 E. Dakota Avenue
Attention: Dee Taylor Fresno, CA 92725
1501 Capitol Avenue, MS 2702 Telephone: 559-600-6055
Sacramento, CA, 95814 Fax: 559-600-6089
Telephone: (916) 713-8509 Email:
Email: Dee.Taylor(c)_dhcs.ca.gov rangeja@fresnocountyca.gov
C. Either party may make changes to the information above by giving written
notice to the other party. Said changes shall not require an amendment to
this contract.
County of Fresno
22-20101 Al
Page 2 of 2
Exhibit A
SCOPE OF WORK
5. General Authority
This Contract is entered into in accordance with the Welfare and Institutions (W&I
Code § 14680 through §14727. W&I Code § 14712 directs the California
Department of Health Care Services (Department) to implement and administer
Managed Mental Health Care for Medi-Cal eligible residents of this state through
contracts with mental health plans. The Department and County of Fresno
agrees to operate the Mental Health Plan (MHP) for Fresno County. No
provision of this contract is intended to obviate or waive any requirements of
applicable law or regulation, in particular, the provisions noted above. In the
event a provision of this contract is open to varying interpretations, the contract
provision shall be interpreted in a manner that is consistent with applicable law
and regulation.
6. Electronic and IT Accessibility Requirements Under the Rehabilitation Act
of 1973 and the Americans with Disabilities Act of 1990
The Contractor agrees to ensure that deliverables developed and produced,
pursuant to this Agreement shall comply with the accessibility requirements of
Section 508 of the Rehabilitation Act of 1973 as amended (29 U.S.C. § 794 (d)),
and regulations implementing that Act as set forth in Part 1194 of Title 36 of the
Code of Federal Regulations (C.F.R.), and the portions of the Americans with
Disabilities Act of 1990 related to electronic and IT accessibility requirements and
implementing regulations. In 1998, Congress amended the Rehabilitation Act of
1973 to require Federal agencies to make their electronic and information
technology (EIT) accessible to people with disabilities. California Government
Code section 11135 codifies section 508 of the Act requiring accessibility of
electronic and information technology.
7. Services to be Performed
See Exhibit A, Attachments 1 through 15 for a detailed description of the services
to be performed.
County of Fresno
22-20101 Al
Page 1 of 6
Exhibit A— Attachment 1
ORGANIZATION AND ADMINISTRATION
1. Implementation Plan
The Contractor shall comply with the provisions of the Contractor's
Implementation Plan as approved by the Department, including the
administration of member "o„ y problem resolution processes. (California
Code of Regulations (Cal. Code Regs.) Title (tit.) 9, §§ 1810.310, 1850.205-
1850.208.) The Contractor shall obtain written approval by the Department prior
to making any changes to the Implementation Plan as approved by the
Department. The Contractor may implement the changes if the Department does
not respond in writing within thirty calendar (30) days. (Cal. Code Regs. tit. 9, §
1810.310(c)(5).)
2. Prohibited Affiliations
A. The Contractor shall not knowingly have any prohibited type of
relationship with the following:
1) An individual or entity that is debarred, suspended, or otherwise
excluded from participating in procurement activities under the
Federal Acquisition Regulation or from participating in non-
procurement activities under regulations issued under Executive
Order No. 12549 or under guidelines implementing Executive Order
No. 12549. (42 C.F.R. § 438.610(a)(1).)
2) An individual or entity who is an affiliate, as defined in the Federal
Acquisition Regulation at 48 C.F.R. § 2.101, of a person described
in this section. (42 C.F.R. § 438.610(a)(2).)
B. The Contractor shall not have a prohibited type of relationship by
employing or contracting with providers or other individuals and entities
excluded from participation in federal health care programs (as defined in
section 112813(f) of the Social Security Act) under either Section 1128 (42
U.S.C. § 1320a-7), 1128A (42 U.S.C. § 1320a-7a), 1156 (42 U.S.C. §
1320c-5), or 18420)(2) (42 U.S.C. § 1395uo)(2)) of the Social Security Act.
(42 C.F.R. §§ 438.214(d)(1), 438.610(b).)
C. The Contractor shall not have types of relationships prohibited by this
section with an excluded, debarred, or suspended individual, provider, or
entity as follows:
County of Fresno
22-20101 Al
Page 2 of 6
Exhibit A— Attachment 1
ORGANIZATION AND ADMINISTRATION
1) A director, officer, agent, managing employee, or partner of the
Contractor. (42 U.S.C. § 1320a-7(b)(8)(A)(ii); 42 C.F.R. §
438.610(c)(1).)
2) A subcontractor of the Contractor, as governed by 42 C.F.R. §
438.230. (42 C.F.R. § 438.610(c)(2).)
3) A person with beneficial ownership of 5 percent or more of the
Contractor's equity. (42 C.F.R. § 438.610(c)(3).)
4) An individual convicted of crimes described in section 1128(b)(8)(B)
of the Act. (42 C.F.R. § 438.808(b)(2).)
5) A network provider or person with an employment, consulting, or
other arrangement with the Contractor for the provision of items
and services that are significant and material to the Contractor's
obligations under this Contract. (42 C.F.R. § 438.610(c)(4).)
6) The Contractor shall not employ or contract with, directly or
indirectly, such individuals or entities for the furnishing of health
care, utilization review, medical social work, administrative
services, management, or provision of medical services (or the
establishment of policies or provision of operational support for
such services). (42 C.F.R. § 438.808(b)(3).)
D. The Contractor shall provide to the Department written disclosure of any
prohibited affiliation identified by the Contractor or its subcontractors. (42
C.F.R. § 438.608(c)(1).)
3. Delegation
Unless specifically prohibited by this contract or by federal or state law, the
Contractor may delegate duties and obligations of Contractor under this contract
to subcontracting entities if the Contractor determines that the subcontracting
entities selected are able to perform the delegated duties in an adequate manner
in compliance with the requirements of this contract. The Contractor shall
maintain ultimate responsibility for adhering to and otherwise fully complying with
all terms and conditions of its contract with the Department, notwithstanding any
County of Fresno
22-20101 Al
Page 3 of 6
Exhibit A— Attachment 1
ORGANIZATION AND ADMINISTRATION
relationship(s) that the Mental Health Plan may have with any subcontractor. (42
C.F.R. § 438.230(b)(1).)
4. Subcontracts
A. This provision is a supplement to provision number five (Subcontract
Requirements) in Exhibit D(F) which is attached hereto as part of this
contract. As allowed by provision five in Exhibit D(F), the Department
hereby, and until further notice, waives its right to prior approval of
subcontracts and approval of existing subcontracts.
B. No subcontract terminates the legal responsibility of the Contractor to the
Department to assure that all activities under this contract are carried out.
(42 C.F.R. § 438.230(b).)
C. All subcontracts shall be in writing.
D. All subcontracts for inpatient and residential services shall require that
subcontractors maintain necessary licensing and certification or mental
health program approval.
E. Each subcontract shall contain:
1) The delegated activities and obligations, including services
provided, and related reporting responsibilities. (42 C.F.R. §
438.230(c)(1)(i).)
2) The subcontractor's agreement to perform the delegated activities
and reporting responsibilities in compliance with the Contractor's
obligations in this Contract. (42 C.F.R. § 438.230(c)(1)(ii).)
3) Subcontractor's agreement to submit reports as required by the
Contractor and/or the Department.
4) The method and amount of compensation or other consideration to
be received by the subcontractor from the Contractor.
5) Requirement that the subcontract be governed by, and construed in
accordance with, all laws and regulations, and all contractual
obligations of the Contractor under this contract.
County of Fresno
22-20101 Al
Page 4 of 6
Exhibit A— Attachment 1
ORGANIZATION AND ADMINISTRATION
6) Requirement that the subcontractor comply with all applicable
Medicaid laws, regulations, including applicable sub-regulatory
guidance and contract provisions. (42 C.F.R. § 438.230(c)(2).)
7) Terms of the subcontract including the beginning and ending dates,
as well as methods for amendment and, if applicable, extension of
the subcontract.
8) Provisions for full and partial revocation of the subcontract,
delegated activities or obligations, or application of other remedies
permitted by state or federal law when the Department or the
Contractor determine that the subcontractor has not performed
satisfactorily. (42 C.F.R. § 438.230(c)(1)(iii).)
9) The nondiscrimination and compliance provisions of this contract.
10) A requirement that the subcontractor make all of its premises,
physical facilities, equipment, books, records, documents,
contracts, computers, or other electronic systems pertaining to
Medi-Cal enrollees, Medi-Cal-related activities, services and
activities furnished under the terms of the subcontract, or
determinations of amounts payable, available at any time for
inspection, examination or copying by the Department, CMS, HHS
Inspector General, the United States Comptroller General, their
designees, and other authorized federal and state agencies. (42
C.F.R. §438.230(c)(3)(i)-(ii).) This audit right will exist for 10 years
from the final date of the contract period or from the date of
completion of any audit, whichever is later. (42 C.F.R. §
438.230(c)(3)(iii).) The Department, CMS, or the HHS Inspector
General may inspect, evaluate, and audit the subcontractor at any
time if there is a reasonable possibility of fraud or similar risk. The
Department's inspection shall occur at the subcontractor's place of
business, premises or physical facilities. (42 C.F.R. §
438.230(c)(3)(iv).)
11) Subcontractor shall maintain books and records of its work
pursuant to its subcontract, in accordance with the general
standards applicable to such book or record keeping, for a term of
at least ten years from the close of the state fiscal year in which the
subcontract was in effect. Subcontractor's agreement that
County of Fresno
22-20101 Al
Page 5 of 6
Exhibit A— Attachment 1
ORGANIZATION AND ADMINISTRATION
assignment or delegation of the subcontract shall be void unless
prior written approval is obtained from the Contractor.
12) A requirement that the Contractor monitor the subcontractor's
compliance with the provisions of the subcontract and this contract
and a requirement that the subcontractor provide a corrective
action plan if deficiencies are identified.
13) Subcontractor's agreement to hold harmless both the State and
members beRefiGiarn in the event the Contractor cannot or does
not pay for services performed by the subcontractor pursuant to the
subcontract.
14) Subcontractor's agreement to comply with the Contractor's policies
and procedures on advance directives and the Contractor's
obligations for Physician Incentive Plans, if applicable based on the
services provided under the subcontract.
5. Accreditation Status
A. The Contractor shall inform the Department whether it has been
accredited by a private independent accrediting entity. (42 C.F.R. §
438.332(a).)
B. If the Contractor has received accreditation by a private independent
accrediting entity, the Contractor shall authorize the private independent
accrediting entity to provide the Department a copy of its most recent
accreditation review, including:
1) Its accreditation status, survey type, and level (as applicable);
2) Accreditation results, including recommended actions or
improvements, corrective action plans, and summaries of findings;
and
3) The expiration date of the accreditation. (42 C.F.R. § 438.332(b).)
6. Conflict of Interest
A. The Contractor shall comply with the conflict-of-interest safeguards
described in 42 Code of Federal Regulations section 438.58 and the
prohibitions described in section 1902(a)(4)(C) of the Social Security Act.
(42 C.F.R. § 438.3(f)(2).)
County of Fresno
22-20101 Al
Page 6 of 6
Exhibit A— Attachment 1
ORGANIZATION AND ADMINISTRATION
B. The Contractor's officers and employees shall not have a financial interest
in this Contract, or a subcontract of this Contract made by them in their
official capacity, or by any body or board of which they are members
unless the interest is remote. (Gov. Code §§ 1090, 1091; 42 C.F.R. §
438.3(f)(2).)
C. No public officials at any level of local government shall make, participate
in making, or attempt to use their official positions to influence a decision
made within the scope of this Contract in which they know or have reason
to know that they have a financial interest. (Gov. Code §§ 87100, 87103;
Cal. Code Regs., tit. 2, § 18704; 42 C.F.R. § 438.3(f)(2).)
1) If a public official determines not to act on a matter due to a conflict
of interest within the scope of this Contract, the Contractor shall
notify the Department by oral or written disclosure. (Cal. Code
Regs., tit. 2, § 18707; 42 C.F.R. § 438.3(f)(2).)
2) Public officials, as defined in Government Code section 87200,
shall follow the applicable requirements for disclosure of a conflict
of interest or potential conflict of interest, once it is identified, and
recuse themselves from discussing or otherwise acting upon the
matter. (Gov. Code § 87105, Cal. Code Regs., tit. 2, § 18707(a); 42
C.F.R. § 438.3(f)(2).)
D. The Contractor shall not utilize in the performance of this Contract any
State officer or employee in the State civil service or other appointed State
official unless the employment, activity, or enterprise is required as a
condition of the officer's or employee's regular State employment. (Pub.
Con. Code § 10410; 42 C.F.R. § 438.3(f)(2).)
1) The Contractor shall submit documentation to the Department of
employees (current and former State employees) who may present
a conflict of interest.
County of Fresno
22-20101 Al
Page 1 of 11
Exhibit A— Attachment 2
SCOPE OF SERVICES
1. Criteria for Members BenefoGua to Access Specialty Mental Health
Services SMHS
Effective January 1, 2022, the Contractor shall implement the criteria for access
to SMHS (except for psychiatric inpatient hospital and psychiatric health facility
services) established below, update the Contractor's policies and procedures as
needed to ensure compliance with this policy effective January 1, 2022, and
communicate these updates to providers as necessary.
In addition, the Contractor shall update member "enry handbooks,
manuals, and related materials to ensure the criteria for SMHS for individuals
under 21 years of age and for adults is accurately reflected in all materials,
including materials reflecting the responsibility of Medi-Cal managed care plans
and the Fee for Service delivery system for covering non-specialty mental health
services. (BHIN 21-073).
A. Pursuant to W&I Code section 14184.402(a) the following
definitions of "medical necessity" or "medically necessary" apply:
1) For individuals 21 years of age or older, a service is "medically
necessary" or a "medical necessity" when it is reasonable and
necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe pain as set forth in W&I Code section
14059.5.
2) For individuals under 21 years of age, a service is "medically
necessary" or a "medical necessity" if the service meets the standards
set forth in Section 1396d(r)(5) of Title 42 of the United States Code.
This section requires provision of all Medicaid-coverable services
needed to correct and ameliorate mental illness and conditions.
Federal guidance from the Centers for Medicare & Medicaid Services
makes it clear that services need not be curative or restorative to
ameliorate a mental health condition. All mental health services that
are not covered under Medi-Cal Fee For Service (FFS) or by Managed
Care Plans as non-specialty mental health services as established in
W&I Code section 14184.402(b) that sustain, support, improve, or
make more tolerable a mental health condition are considered to
ameliorate the mental health condition are thus medically necessary
and covered as EPSDT services and the Contractor shall cover them
County of Fresno
22-20101 Al
Page 2 of 11
Exhibit A— Attachment 2
SCOPE OF SERVICES
for members b8Refiniarioo who meet the criteria for access to the
specialty mental health delivery system.
Services provided to a member be aFy must be medically
necessary and clinically appropriate to address the member's
beRefiGiaFYL presenting condition.
B. Criteria for Adult Members BeRefiniorioo to Access the Specialty Mental
Health Services Delivery System
For members beRefiniarioc 21 years of age or older, the Contractor shall
provide covered specialty mental health services for members
beRefiG.aries who meet both of the following criteria, (1) and (2) below:
1. The member beRefiGiary has one or both of the following:
a. Significant impairment, where impairment is defined as distress,
disability, or dysfunction in social, occupational, or other
important activities
b. A reasonable probability of significant deterioration in an
important area of life functioning
AND
2. The member's beRefiniar condition as described in paragraph (1) is
due to either of the following:
a. A diagnosed mental health disorder, according to the criteria of
the current editions of the Diagnostic and Statistical Manual of
Mental Disorders and the International Statistical Classification
of Diseases and Related Health Problems
b. A suspected mental disorder that has not yet been diagnosed
C. Criteria for Members BeRefiGiarioc under Age 21 to Access the Specialty
Mental Health Services Delivery System
For enrolled members benefiGiarioc under 21 years of age, Contractor
shall provide all medically necessary specialty mental health services
required pursuant to Section 1396d(r) of Title 42 of the United States
Code. Covered specialty mental health services shall be provided to
enrolled members beRefiniarioc who meet either of the following criteria:
County of Fresno
22-20101 Al
Page 3 of 11
Exhibit A— Attachment 2
SCOPE OF SERVICES
1) The member hoRefiGiary has a condition placing them at high risk for a
mental health disorder due to experience of trauma evidenced by any
of the following: scoring in the high-risk range under a trauma
screening tool approved by the department, involvement in the child
welfare system, juvenile justice involvement, or experiencing
homelessness.
OR
2) The member ho„, ry meets both of the following requirements in a
and b below:
a. The member beRefiGiary has at least one of the following:
i. A significant impairment
ii. A reasonable probability of significant deterioration in an
important area of life functioning
iii. A reasonable probability of not progressing developmentally
as appropriate
iv. A need for specialty mental health services, regardless of
presence of impairment, that are not included within the
mental health benefits that a Medi-Cal managed care plan is
required to provide
AND
b. The member's benefiGiary's condition as described in
subparagraph (A) is due to one of the following:
i. A diagnosed mental health disorder, according to the criteria
of the current editions of the Diagnostic and Statistical
Manual of Mental Disorders and the International Statistical
Classification of Diseases and Related Health Problems
ii. A suspected mental health disorder that has not yet been
diagnosed
iii. Significant trauma placing the member beRefiGiary at risk of a
future mental health condition, based on the assessment of a
licensed mental health professional
County of Fresno
22-20101 Al
Page 4 of 11
Exhibit A— Attachment 2
SCOPE OF SERVICES
2. Provision of Services
A. The Contractor shall provide or arrange, and pay for, the following
medically necessary covered specialty mental health services to
members benefiGiarioo who meet access criteria for receiving specialty
mental health services. See Exhibit E, Attachment 2, Service Definitions,
for detailed descriptions of the specialty mental health services listed
below:
1) Mental health Services;
2) Medication Support Services;
3) Day Treatment Intensive;
4) Day Rehabilitation;
5) Crisis Intervention;
6) Crisis Stabilization;
7) Adult Residential Treatment Services;
8) Crisis Residential Treatment Services;
9) Psychiatric Health Facility Services;
10) Intensive Care Coordination (for members beRefiGiari under the
age of 21);
11) Intensive Home Based Services (for members benefi^iari under
the age of 21);
12) Therapeutic Behavioral Services (for members benefiGiari under
the age of 21);
13) Therapeutic Foster Care (for members benefiGiarioc under the age
of 21);
14) Psychiatric Inpatient Hospital Services;
County of Fresno
22-20101 Al
Page 5 of 11
Exhibit A— Attachment 2
SCOPE OF SERVICES
15) Targeted Case Management;
16) Peer Support Services (If the Contractor has opted to provide Peer
Support Services and has been approved by DHCS, the Contractor
shall comply with the peer support services provisions in
Attachment 15); aPA
17) For members beRefiGiari under the age of 21, the Contractor
shall provide all medically necessary specialty mental health
services required pursuant to Section 1396d(r) of Title 42 of the
United States Code (W&I Code § 14184.402 (d)); and
18) Community-Based Mobile Crisis Intervention Services (also
referred to as "Mobile Crisis Services") (BHIN 23-025).
B. Medi-Cal Managed Care Plan members beRefiGiari receive mental
health disorder benefits in every classification - inpatient, outpatient,
prescription drug and emergency - that the members beRefiGiari receive
medical/surgical benefits, in compliance with 42 C.F.R. section
438.910(b)(2). The Contractor is only required to provide inpatient and
outpatient specialty mental health services, as provided for in this Contract
and as required pursuant to section 1396d(r) of Title 42 of the United
States Code, as prescription drug and emergency benefits are provided
through other delivery systems. Emergency and post-stabilization
services described in 42 C.F.R. § 438.114 are not provided as
specialty mental health services covered by Contractor. Emergency
and post-stabilization services for all Medi-Cal members are covered
through the capitation payment made to Medi-Cal Managed Care
Plans or through fee-for-service. Contractor shall provide psychiatric
inpatient hospital services, psychiatric health facilities services,
crisis intervention, crisis stabilization, and crisis residential services
and comply with relevant provisions for emergency admission to a
psychiatric inpatient hospital as required by Attachment 3 of Exhibit
A to this Agreement; however, this is not equivalent to emergency
services described in 42 CFR § 438.114. Medi-Cal Managed Care
Plans shall cover and pay for emergency room professional services
pursuant to Cal. Code Regs., tit. 22 §53855, including all professional
physical, mental, and substance use treatment services, including
County of Fresno
22-20101 Al
Page 6 of 11
Exhibit A— Attachment 2
SCOPE OF SERVICES
screening examinations necessary to determine the presence or
absence of an emergency medical condition, and, if an emergency
medical condition exists, for all services medically necessary to
stabilize the member. Managed Care Plans shall cover and pay for
facility charges for emergency room visits (BHIN 22-011 and APL 22-
0
C. Services shall be provided, in accordance with the State Plan, to
members beRefiGiari who meet criteria to access SMHS, documented
in accordance with state and federal requirements.
D. The Contractor shall provide or arrange and pay for all medically
necessary covered specialty mental health services in a sufficient amount,
duration, and scope to reasonably achieve the purpose for which the
services are furnished. The Contractor shall not arbitrarily deny or reduce
the amount, duration, or scope of a medically necessary covered specialty
mental health service solely because of diagnosis, type of illness, or
condition of the member beRefiGiary. The Contractor may deny services
based on W&I Code sections 14184.402, subdivisions (a), (c), and (d),
14059.5; and departmental guidance and regulation. (42 C.F.R. §
438.210(a)(2) and (3).)
E. The Contractor shall make all medically necessary covered specialty
mental health services available in accordance with Cal. Code-Regs., tit.
9, sections1810.345, 1810.350 and 1810.405, and 42 Code of Federal
Regulations part 438.210.
F. The Contractor shall provide second opinions from a network provider or
arrange for the member benefiGiary to obtain a second opinion outside the
network, at no cost to the member ben ary. (42 C.F.R § 438.206(b).)
At the request of a member benefiGiary when the Contractor or its network
provider has determined that the member benefiGiary is not entitled to
specialty mental health services due to not meeting the criteria for access
to SMHS, the contractor shall provide for a second opinion by a licensed
mental health professional (other than a psychiatric technician or a
licensed vocational nurse). (Cal. Code Regs., tit. 9, § 1810.405(e).)
G. The Contractor shall provide a member's beRefiGiary's. choice of the
person providing services to the extent feasible in accordance with Cal.
Code-Regs., tit. 9, section 1830.225 and 42 Code of Federal Regulations
part 438.3(I).
County of Fresno
22-20101 Al
Page 7 of 11
Exhibit A— Attachment 2
SCOPE OF SERVICES
3. Requirements for Day Treatment Intensive and Day Rehabilitation
A. The Contractor shall require providers to request prior authorization for
day treatment intensive and day rehabilitation services, in accordance with
Information Notice 22-016 and any subsequent departmental notices.
B. The Contractor shall require that providers of day treatment intensive and
day rehabilitation meet the requirements of Cal. Code Regs., tit. 9, §§
1840.318, 1840.328, 1840.330, 1840.350 and 1840.352.
C. The Contractor shall require that providers include, at a minimmon one or
more of the following day treatment intensive and day rehabilitation
service components: assessment, treatment planning, therapy,
psychosocial rehabilitation. Both services must have a clearly
established site for services although all services need not to be
delivered at that site and some service components may be delivered
through telehealth or telephone.
1 ThoranocacTG mmlTeu. Thi' ofMUSt ORG16ide nrE)GeSS gFO i S
an�kill building groups. Spcnif�ac� �s shall�performedby
,UddartFfFed staff and take plaGe dUFiRg the SGhedule`� �'ca hourrvr
oep eera inn of the pregram The goal n�eterapcatiG milieu is
feanh medel and reinferne nenstrU UGtiye interanfiens by iRVGIVino
U r
beRefiGiaries OR r everall preoram. For exam�beRefiGiari�es are
previded with epperfU Unifies to loon r•emmU Unity meetings and to
prepside edbaGk to peers.The preoram inrIU Ui�Ades behcha v i-
management interventions that fenU Us en teoehiRg self management
shills that nhildren and adults and older adults may use to nentrel
their eWR liVes fe !deal effenfiyely with present and fU UtU Ure problems,
U
and to fU Unntinn well with minimal or no additional fherapeU Utin
0 RteWeRtOGR. AGtiVitieS On�nlU U e, but aTU re net limited to staff feedhanli
to henefiniaries en strategies fer symptem redU Untien ipnreasinn
U
adaptive hehayiers, a—and red61Gi ubjeetive-distress.
2\ Droness groups. These groups, fanGilitated by staff, shal�sssit
eanh henefiGiary to develop penessary shills to deal with their
prehl s and issues. The group preness shall utilize peer
prvpre��-u�-ra-rrracv.
0Rteraetion and feedhagL in developing prehlem sohiing strategies
County of Fresno
22-20101 Al
Page 8 of 11
Exhibit A— Attachment 2
SCOPE OF SERVICES
to reselve behavioral and evnotional problems. Day r ehabilita+inn
May innli fide psYnhotherapy instead of process grei rps or in
e
addition to progess groi ips
` ) Chill hi iildin groi i S. In those grei ips staffhallll help be Refini�?
identif�i barriers related to their psYnhiatrin and psYgheleginal
ape --es. Thro
ugh ghgh the GE)i arse of groi ip inteWaGtOGR,beRefn'` iaFieS
identify skills that address sYmptoms and increase adap#y-e
behayoers
perta-vrvrs
4) AdiUnotoye therapies. T;es�eterapies in whiG both Staff andd
beRefiGiarieszr'�ute. These therapies may utilizes•etf
press• n SLJGh as art re tion daRGe er mUsio as the
therapei stir• intervention Dartioipants do net need to have anY level
of skill in the area of self expression, but ht rather he able utilize the
mrn rd ytd RGe skills rlirenteld nior`d oGhieyinn
�r��rcccccr T Trrg
heneflr•lary plan goals Adii RGtiye therapies assist the heneflr•lary in
attaining er restering skills whinh enhange r•ommi unity fi inntiening
Inr•II iding problem sohiing organization of thoughts and materials
e e
and verbalization of ideas and feelings Arlie inntiVe therapies
provided as a r+omponent of day rehabilitation or day treatment
intensive are used in genii ipgtien with other mental health serVines
iR Grdder to impreve the G6ltnr+me of those SGFViGeS`+o�Jt nt with
the heneflglar\/'S needs
D. Day treatment intensive shall •n e-
1\ PSYGhetherapy. PSYGhotherapy F}eaRS the use of PSYGheeleg!G-al
metheds within a professional relationship to assist the benefigiary
er benefiGiaries to anhieye a better psYohesor•ial adaptation to
e
angi lire a greater hi roan realization of psYnhosooial potential and
adaptatien to medify internal and external nonditiens that affent
i ndiyidi iale i gro rpse i i or nommnities in respent to behayier, emotions
e
and thinking in respect to their intrapersonal and interpersonal
processes DsYnhetherapy shall he previded by linensed
registered, or waivered staffpracticing within their scope of
pprraGtiGe. PSYGhotherapy does ROt ORGlude physie�ggiGaal
I nteryentlense i i inclding medication in+eryen+inn
County of Fresno
22-20101 Al
Page 9 of 11
Exhibit A— Attachment 2
SCOPE OF SERVICES
� Health GF060S Dr�oQrol.The ('�a� r Sh�alTl�61reettrhraatt
t"
-�/� heFE? io are established PFGtr)nnl fnr FeSpeRdiRg to horiofini�rioo
2�C12 I—Rg a M8Rtal health GF0606. The PFGt^yrncvl shall assure the
availability of appFep Fiately trained and q ialified Staff and irin161de
awe E, dares for addre66 I�GHSiS SriuiartirGRs. The
Protonol may ORGli de referrals fer nriSiS iriterieritior nriSiS
e
stabiliZatiGR
e
(Gri sserv+ryes) If the preteGel ORGludes refer the day
treatment intenSiye er day rehabilitation oregram Staff shall have
the naoanity to handle the nrisis URN the heneflnlary is IiRked to an
outside nrisiS Sel"v1—
3) WritteR Weekly Schedule The CORtran� Shall eRSUTetha�t a
c.�u�rr�c-wiTcrac �riurr
weekly detailed SGherdi le is available to henefiniaries and as
apprepriate to their families nareg-JI— S or —zJSionifinant Si iPPOA
perSeRS and ideRtifie�hen and where the serVTGe `"�ggneriSof
the oreoram will he oreyided and by whom. The writ'te�n�rvw"e'�eke
Sashed ile will SoeGify the oreoram staff, f i their oalifinatiGRS, t an the
SSoPe of their SeFVOGeS
E. Staffing Requirements. Staffing ratios shall be consistent with the
requirements in Cal. Code Regs., tit. 9, section 1840.350, for day
treatment intensive, and Cal. Code Regs., tit. 9 section 1840.352 for day
rehabilitation. For day treatment intensive, staff shall include at least one
staff person whose scope of practice includes psychotherapy.
a. Program staff may be required to spend time on day treatment intensive
and day rehabilitation activities outside the hours of operation and
therapeutic program (e.g., time for travel, documentation, and caregiver
contacts).
b. The Contractor shall require that at least one staff person be present and
available to the group in the therapeutic milieu for all scheduled hours of
operation.
c. The Contractor shall require day treatment intensive and day rehabilitation
programs to maintain documentation that enables the Contractor and the
Department to audit the program if it uses day treatment intensive or day
County of Fresno
22-20101 Al
Page 10 of 11
Exhibit A— Attachment 2
SCOPE OF SERVICES
rehabilitation staff who are also staff with other responsibilities (e.g., as
staff of a group home, a school, or another mental health treatment
program). The Contractor shall require that there is documentation of the
scope of responsibilities for these staff and the specific times in which day
treatment intensive or day rehabilitation activities are being performed
exclusive of other activities.
F. The Contractor shall ensure that the provider receives Medi-Cal
reimbursement only if the member beRefiGiary is present for at least 50
percent of scheduled hours of operation for that day. In cases where
absences are frequent, it is the responsibility of the Contractor to ensure
that the provider re-evaluates the member's beRefi^iary's need for the
day rehabilitation or day treatment intensive program and takes
appropriate action.
G. Documentation Standards. The Contractor shall ensure day treatment
intensive and day rehabilitation documentation meets the documentation
requirements in BHIN 22-019.
H. The Contractor shall ensure that day treatment intensive and day
rehabilitation have at least one contact per month with a family member,
caregiver or other significant support person identified by an adult
member hery, or one contact per month with the legally responsible
adult for a member benefiGiaFY who is a minor. This contact may be face-
to-face, or by an alternative method (e.g., e-mail, telephone, etc.). Adult
members beRefiGiar; may decline this service component. The
contacts should focus on the role of the support person in supporting the
member's beRefiGiar„'s community reintegration. The Contractor shall
ensure that this contact occurs outside hours of operation and outside the
therapeutic program for day treatment intensive and day rehabilitation.
I. Written Program Description. The Contractor shall ensure there is a
written program description for day treatment intensive and day
rehabilitation. The written program description must describe the specific
activities of each service and reflects each of the required components of
the services as described in this section. The Contractor shall review the
written program description for compliance with this section with prior to
the date the provider begins delivering day treatment intensive or day
rehabilitation.
County of Fresno
22-20101 Al
Page 11 of 11
Exhibit A— Attachment 2
SCOPE OF SERVICES
J. Continuous Hours of Operation. The Contractor shall ensure that the
provider applies the following when claiming for day treatment intensive
and day rehabilitation services:
a. A half day shall be billed for each day in which the member r,or, F
receives face-to-face services in a program with services available four
hours or less per day. Services must be available a minimum of three
hours each day the program is open.
b. A full-day shall be billed for each day in which the member "e^ ry
receives face-to-face services in a program with services available more
than four hours per day.
c. Although the member "en ;G,ry must receive face to face services on
any full-day or half-day claimed, all service activities during that day are
not required to be face-to-face with the member "enry.
d. The requirement for continuous hours of operation does not preclude short
breaks (for example, a school recess period) between activities. A lunch or
dinner may also be appropriate depending on the program's schedule.
The Contractor shall not conduct these breaks toward the total hours of
operation of the day program for purposes of determining minimum hours
of service.
4. Therapeutic Behavioral Services
Therapeutic Behavioral Services (TBS) are specialty mental health services
covered as Early and Periodic Screening, Diagnostic and Treatment (EPSDT).
(Cal. Code Regs., tit. 9, § 1810.215.) TBS are intensive, one-to-one services
designed to help members beRefiGiarioc and their parents/caregivers manage
specific behaviors using short-term measurable goals based on the member's
beRefiniaryis needs. TBS is described in the Department of Mental Health
Information Notice 08-38.
County of Fresno
22-20101 Al
Page 1 of 6
Exhibit A— Attachment 3
FINANCIAL REQUIREMENTS
1. Provider Compensation
The Department shall ensure that no payment is made to a network provider
other than by the Contractor for services covered under this agreement, except
when these payments are specifically required to be made by the Department in
Title XIX of the Act, in 42 CFR chapter IV. (42 C.F.R. § 438.60.)
2. Payments for Indian Health Care Providers
A. The Contractor shall make payment to all Indian Health Care Providers
(IHCPs) (42 CFR § 438.14(a)) in its network in a timely manner as
required for payments to practitioners in individual or group practices
under 42 C.F.R. §§ 447.45 and 447.46 including paying 90% of all clean
claims from practitioners within 30 days of the date of receipt and paying
99 percent of all clean claims from practitioners within 90 days of the date
of receipt. (42 C.F.R. § 438.14(b)(2).)
B. The Contractor shall pay an IHCP that is not enrolled as a FQHC,
regardless of whether it is a network provider of the Contractor, its
applicable encounter rate published annually in the Federal Register by
the Indian Health Service or in the absence of a published encounter rate,
the amount the IHCP would receive if the services were provided under
the State plan's fee-for-service methodology. (42 C.F.R. § 438.14 (c)(2).)
C. The Contractor shall comply with guidance issued by DHCS regarding
Payments for Indian Health Care Providers, including BHIN 22-020 and
any subsequent information notices.
D. To initiate payment, Contractor shall require IHCPs to submit claims
in accordance with claiming requirements. The rate on the claim
should reflect the rate the IHCP should be paid for the service in
accordance with Department guidance. If the rate claimed is
incorrect for any reason, the amount due to the IHCP from
Contractor shall be consistent with the guidance in BHIN 22-020 and
subsequent information notices. Contractor shall pay claims from
IHCPs in accordance with the timeliness requirements in 42 CFR §§
438.14(b)(2)(iii), 447.45, and 447.46.
County of Fresno
22-20101 Al
Page 2 of 6
Exhibit A— Attachment 3
FINANCIAL REQUIREMENTS
3. Prohibited Payments
A. Federal Financial Participation is not available for any payment amount
for services furnished by an excluded individual or entity, or at the
direction of a physician during the period Of GXGIUSOG1 such physician is
excluded when the person providing the service knew or had reason to
know of the exclusion, or to an individual or entity when the Department
failed to suspend payments during an investigation of a credible allegation
of fraud. (42 U.S.C. § 1396b(i)(2).)
B. In accordance with Section 1903(i) of the Social Security Act, the
Contractor is prohibited from paying for an item or service:
1) Furnished under this Contract by any individual or entity during any
period when the individual or entity is excluded from participation under
title V, XVIII, or XX or under this title pursuant to sections 1128, 1128A,
1156, or 18420)(2) of the Social Security Act.
2) Furnished at the medical direction or on the prescription of a physician,
during the period when such physician is excluded from participation
under title V, XVI 11, or XX or under this title pursuant to sections 1128,
1128A, 1156, or 18420)(2) of the Social Security Act and when the
person furnishing such item or service knew, or had reason to know, of
the exclusion (after a reasonable time period after reasonable notice
has been furnished to the person).
3) Furnished by an individual or entity to whom the state has failed to
suspend payments during any period when there is a pending
investigation of a credible allegation of fraud against the individual or
entity, unless the state determines there is good cause not to suspend
such payments.
4) With respect to any amen+ expeR ed services or activities
furnished for which funds may not be used under the Assisted Suicide
Funding Restriction Act (ASFRA) of 1997.
4. Emergency Admission for Psychiatric Inpatient Hospital Services
The Contractor shall comply with Cal.Code Regs. Tit. 9 § 1820.225 regarding
emergency admission for psychiatric inpatient hospital services regarding
authorization and payment for both contract and non-contract hospitals.
County of Fresno
22-20101 Al
Page 3 of 6
Exhibit A— Attachment 3
FINANCIAL REQUIREMENTS
5. Audit Requirements
The Contractor shall submit audited financial reports specific to this Contract on
an annual basis. The audit shall be conducted in accordance with generally
accepted accounting principles and generally accepted auditing standards. (42
C.F.R. § 438.3(m).)
6. Cost Reporting
A The rc CORtraacter shall subbmit a fiSGal year eRd GOcrt repOrt Rv later tFIaR
December 31 feIIeWing the GIlese of eaaGh ff'rsGacal year, OR with
the NQI Welf. & Inc+, Conde § 14705(c\ i finless that date is evtenrderd by the
v-a-oci--rrcn. c�.rrr�-rcrr-au�rc-rr T rcr-rcrca--rTy--cr-rc
Department, rd an /er guidelines establisherd by the Departmep+ Data
submitted shall be full and GOMplete and the GGSt report shall be Gertified
bythe Gentractar's Mental Health flirecter anrd age of the falla\enng• (1) the
('antracter's chief financial efficer (ar eq iiyalent) (2) an inrdiyirdi ial whe
e
hasas dele- -i o sign fere rd an reperts to ireetly the (`antra GtGF' �e
chief financial afficere (`or (3) the nntrantnr's ai irditar cantraller nr
e
eq-l� aleat. The ceSt-reshallth the ( nnrt� ' $sris anra
the nest of its si ibcantractars e rd if aRy. The cost revert shall he cemplete in
aGGOrdaRGe with instri ictinns contained in the Department's Gest and
Financial Reporting System Instrl ictian Manual which can he accessed
through the Department's Informatien Technelegy Web Ser\/Ices (ITWS)
fer the appliGable year, well as aRy iTRStFac+�Sthat eGOrp�zgdy
refereRGe thereto; how the tent � en�r+tnr disagrees
with ""''77
e��el=te�e�c rcrr� crr�r-a,�a9,z��
with si ich instn actions e gi it may raise that rdisagreemept in writing with the
Depar+mept at the time the cast report is filed, rd an shall have the right to
appeal si ich rdisagreemep+ pursuant to Procedures developed i inrder the
\/ &I Welf. A. Ins+ Code § 14174,
B. IIrR aEr^�rdampGe with \Arri-v&I Wets. & Inc+ Code § 5655 the Departments aslri
preyirde technical assistance aprd copse iltatinn to the Gentractor regarding
the preparatiep aprd si ibmissien of timely cost reports If the Geptractnr
does net submit ��cosreport the repoK��eardliRe ipcli finding aRy
�..rc��mr� c�..r "'hh''`"'�. cua�mc�rr-r r�
extepsien period granted by the Department, p the Deartment in
e
accordance with W&I Wel f Q Inc+ Code § 1 A 1 97 7(e)(1) may withheld
payments of ardrditienal fi inrds Until the nest revert that is due has been
submitted,
County of Fresno
22-20101 Al
Page 4 of 6
Exhibit A— Attachment 3
FINANCIAL REQUIREMENTS
not sreFViGe and a eertifinatien statement that has been signed by the
(;E)Rtra is MeRtalHealth and ene of the fnllE)WiRg: 1\ the
Gentraetor's Chief Flnannlal Offiner (or eq iiyalent) (2) an individual who
has delegated au rit y t SigR for, andan reports-directly7 to the (`nntrae�?
`
Chief Finonnial Officer or (3) the GO inty's ai�rditor /+ontroller, or equivalent,
e e ,
its preliminary settlement the department shall so notify the Gentraeter if
edditienal CCD is due to the (`G tra�M tE)P.T,, he D eetq shall
Glai�othefed ve ent for the related FFP within 30 dads
pnntingent i Ipen si 1ffisient budget ai itherity If fi lR ds are due to the State,
the department shall inVeiee the CE)ntraeter anrd the Centraeter shall
retUrn the eyerpayment to the department
7. Recovery of Overpayments
A. The Contractor, and any subcontractor or any network provider of the
Contractor, shall report to the Department within 60 calendar days when it
has identified payments in excess of amounts specified for reimbursement
of Medicaid services. (42 C.F.R. § 438.608(c)(3).)
B. The Contractor, or subcontractor, to the extent that the subcontractor is
delegated responsibility for coverage of services and payment of claims
under this Contract, shall implement and maintain arrangements or
procedures that include provision for the suspension of payments to a
network provider for which the State, or the Contractor, determines there
is a credible allegation of fraud. (42 C.F.R. §§ 438.608(a)(8) and 455.23.)
C. The Contractor shall specify the retention policies for the treatment of
recoveries of all overpayments from the Contractor to a provider, including
specifically the retention policies for the treatment of recoveries of
overpayments due to fraud, waste, or abuse. The policy shall specify the
process, timeframes, and documentation required for reporting the
recovery of all overpayments. The Contractor shall require its network
providers to return any overpayment to the Contractor within 60 calendar
days after the date on which the overpayment was identified. The
Contractor shall also specify the process, timeframes, and documentation
required for payment of recoveries of overpayments to the Department in
situations where the Contractor is not permitted to retain some or all of the
recoveries of overpayments. Contractor shall comply with the reporting
County of Fresno
22-20101 Al
Page 5 of 6
Exhibit A— Attachment 3
FINANCIAL REQUIREMENTS
requirements, and other requirements, in BHIN 19-034. (42 C.F.R. §
438.608(d).)
8. Physician Incentive Plans
A. The Contractor shall obtain approval from the Department prior to
implementing a Physician Incentive Plan between the Contractor and a
subcontractor (Cal. Code Regs. tit. 9, § 1810.438(h).).
1) Pursuant to 42 Code of Federal Regulations part 438.3(i), the
Contractor shall comply with the requirements set forth in 42 C.F.R.
§§ 422.208 and 422.210.
2) Specific payment can be made directly or indirectly under a
Physician Incentive Plan to a physician or physician group as an
inducement to reduce or limit medically necessary services
furnished to a member he^ ry. (42 C.F.R. § 422.208(c)(1).)
3) If a physician or physician group is put at substantial financial risk
for services not provided by the physician/group, the Contractor
shall ensure adequate stop-loss protection to individual physicians
and conduct annual member "enry surveys. (42 C.F.R. §§
422.208(c)(2).)
4) The Contractor shall provide information on its Physician Incentive
Plan to any Medicaid member "enry upon request (this
includes the right to adequate and timely information on a Physician
Incentive Plan). Such information shall include: whether the
Contractor uses a physician incentive plan that affects the use of
referral services, (2) the type of incentive arrangement, and (3)
whether stop-loss protection is provided. (42 C.F.R. § 422.210(b).)
9. Financial requirements
A. The Contractor shall not impose financial requirements or cumulative
financial requirements, as defined in 42 C.F.R. section 438.900, for any
member benefiGiary receiving specialty mental health services.
County of Fresno
22-20101 Al
Page 6 of 6
Exhibit A— Attachment 3
FINANCIAL REQUIREMENTS
10. ICD- 10
A. The Contractor shall use the criteria sets in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5), or current edition, as
the clinical tool to make diagnostic determinations.
Once a DSM-5 mental health disorder diagnosis is determined, the
Contractor shall determine the corresponding mental health diagnosis, in
the International Classification of Diseases and Related Health Problems,
Tenth Revision (ICD-10), or current edition. The Contractor shall use the
ICD-10 diagnosis code(s) to submit a claim for specialty mental health
services to receive reimbursement of Federal Financial Participation
(FFP).
County of Fresno
22-20101 Al
Page 1 of 4
Exhibit A— Attachment 4
MANAGEMENT INFORMATION SYSTEMS
1. Health Information Systems
A. The Contractor shall maintain a health information system that collects,
analyzes, integrates, and reports data. (42 C.F.R. § 438.242(a); Cal. Code
Regs., tit. 9, § 1810.376.) The system shall provide information on areas
including, but not limited to, utilization, claims, grievances, and appeals.
(42 C.F.R. § 438.242(a).) The Contractor shall comply with Section
6504(a) of the Affordable Care Act which requires that State claims
processing and retrieval systems are able to collect data elements
necessary to enable the mechanized claims processing and information
retrieval systems in operation by the State to meet the requirements of
section 1903(r)(1)(F) of the Social Security Act. (42 C.F.R. §
438.242(b)(1).)
B. The Contractor's health information system shall, at a minimum:
1) Collect data on member "enry and provider characteristics as
specified by the Department, and on services furnished to
members beRefiGiar; as specified by the Department; (42 C.F.R.
§ 438.242(b)(2).)
2) Ensure that data received from providers is accurate and complete
by:
a. Verifying the accuracy and timeliness of reported data,
including data from network providers compensated on the
basis of capitation payments; (42 C.F.R. § 438.242(b)(3)(i).)
b. Screening the data for completeness, logic, and consistency;
and (42 C.F.R. § 438.242(b)(3)(ii).)
C. Collecting service information in standardized formats to the
extent feasible and appropriate, including secure information
exchanges and technologies utilized for quality improvement
and care coordination efforts. (42 C.F.R. § 438.242(b)(3)(iii).)
3) Make all collected data available to the Department and, upon
request, to CMS. (42 C.F.R. § 438.242(b)(4).)
County of Fresno
22-20101 Al
Page 2 of 4
Exhibit A— Attachment 4
MANAGEMENT INFORMATION SYSTEMS
B. The Contractor's health information system is not required to collect and
analyze all elements in electronic formats. (Cal. Code Regs., tit. 9, §
1810.376(c).)
2. Encounter Data
The Contractor shall submit encounter data to the Department at a frequency
and level specified by the Department and CMS. (42 C.F.R. § 438.242(c)(2).)
The Contractor shall ensure collection and maintenance of sufficient member
"e^ r encounter data to identify the provider who delivers service(s) to the
member hory. (42 C.F.R. § 438.242(c)(1).) The Contractor shall submit all
member "ems encounter data that the Department is required to report to
CMS under § 438.818. (42 C.F.R. § 438.242(c)(3).) The Contractor shall submit
encounter data to the state in standardized Accredited Standards Committee
(ASC) X12N 837 and National Council for Prescription Drug Programs (NCPDP)
formats, and the ASC X12N 835 format as appropriate. (42 C.F.R. §
438.242(c)(4).)
3. Interoperability Rule Patient Access Application Programming Interface
In compliance with the terms of BHIN 22-068 or further guidance issued by
the Department, Contractor shall implement and maintain a secure,
standards-based Patient Access Application Programming Interface (API)
and a publicly accessible, standards-based Provider Directory API that can
connect to mobile applications and be available through a public-facing
digital endpoint on Contractor's website. (45 C.F.R. § 170.215; 42 C.F.R. §§
431.60, 431.70, and 438.10, 438.242.)
4. MEDSLITE Access
The Contractor shall perform the following:
A. Establish County Behavioral Health MEDSLITE Coordinators (MEDSLITE
Coordinators) to work with DHCS. These MEDSLITE Coordinators are
required to sign and submit an Oath of Confidentiality to DHCS. Only
these designated MEDSLITE Coordinators may initiate requests to add,
delete, or otherwise modify a MEDSLITE user account. These MEDSLITE
Coordinators are responsible for maintaining an active list of the
Contractor's users with MEDSLITE access and collecting a signed
MEDSLITE Oath of Confidentiality from each user. The MEDSLITE
County of Fresno
22-20101 Al
Page 3 of 4
Exhibit A— Attachment 4
MANAGEMENT INFORMATION SYSTEMS
Coordinators are responsible for ensuring users are informed they cannot
share user accounts, that MEDSLITE is to be used for only authorized
purposes, and that all activity is logged. The MEDSLITE Coordinators may
be changed by written notice to DHCS. They should be employees at an
appropriate level in the organization, with sufficient responsibility to carry
out the duties of this position. The MEDSLITE Coordinators will provide,
assign, delete, and track user login identification information for authorized
staff members. They are responsible for ensuring processes are in place
which result in prompt MEDSLITE account deletion requests when the
Contractor's users leave employment or no longer require access due to
change in job duties.
B. Ensure that information furnished or secured via MEDSLITE shall be used
solely for the purposes described in this Agreement. The information
obtained from MEDSLITE shall be used exclusively to administer the
Medi-Cal program. The Contractor further agrees that information
obtained under this Agreement will not be reproduced, published, sold, or
released in original or any other form for any purpose other than identified
in this Agreement.
C. Ensure that any agents, including a subcontractor, (if prior approval is
obtained from DHCS) to whom they provide DHCS data, agree in writing
to the same requirements for privacy and security safeguards for
confidential data that apply to the Contractor with respect to this
Agreement. The Contractor shall seek prior written approval from DHCS
before providing DHCS data to a subcontractor.
D. Adhere to security and confidential provisions outlined in Exhibit F, the
Privacy and Security Provisions for the protection of any information
exchanged between County of Fresno and the DHCS.
E. During the term of this Agreement, the Contractor agrees to implement
reasonable systems for the discovery and prompt reporting of any breach
or security incident involving DHCS data following the process outlined
within Section 17 of Exhibit F, the Privacy and Security Provisions of this
Agreement.
County of Fresno
22-20101 Al
Page 4 of 4
Exhibit A— Attachment 4
MANAGEMENT INFORMATION SYSTEMS
F. In order to enforce this MEDSLITE Access provision, the Contractor
agrees to assist DHCS in performing compliance assessments. These
assessments may involve compliance review questionnaires, and/or
review of the facilities, systems, books, and records of the Contractor, with
reasonable notice from DHCS. Such reviews shall be scheduled at times
that take into account operational and staffing demands. The Contractor
agrees to promptly remedy all violations of any provision of this
Agreement and certify the same to DHCS in writing, or to enter into a
written Corrective Action Plan with DHCS containing deadlines for
achieving compliance with specific provisions of this Agreement.
5. 274 Provider Network Data Reporting
A. The Contractor is required to submit provider network data to DHCS
using the 274 standard on a monthly basis and must be submitted
between the 1st and 10th of each month. (42 C.F.R. 438.207(a))
B. The Contractor shall complete data submission pursuant to DHCS
BHIN 22-032 and any subsequent guidance issued by the
department.
County of Fresno
22-20101 Al
Page 1 of 7
Exhibit A— Attachment 5
QUALITY IMPROVEMENT SYSTEM
1. Quality Assessment and Performance Improvement
A. The Contractor shall implement an ongoing comprehensive Quality
Assessment and Performance Improvement (QAPI) Program for the
services it furnishes to members beRefiGiaFi (42 C.F.R. § 438.330 (a).)
B. The Contractor's QAPI Program shall improve the Contractor's
established outcomes through structural and operational processes and
activities that are consistent with current standards of practice.
C. The Contractor shall have a written description of the QAPI Program that
clearly defines the QAPI Program's structure and elements, assigns
responsibility to appropriate individuals, and adopts or establishes
quantitative measures to assess performance and to identify and prioritize
area(s) for improvement. The Contractor shall evaluate the impact and
effectiveness of its QAPI Program annually and update the Program as
necessary per Cal. Code Regs., tit. 9, § 1810.440(a)(6). (42 C.F.R. §
438.330(e)(2).)
D. The QAPI Program shall include collection and submission of performance
measurement data required by the Department, which may include
performance measures specified by CMS. The Contractor shall measure
and annually report to the Department its performance, using the standard
measures identified by the Department. (42 C.F.R. § 438.330 (a)(2),
(b)(2), (c)(2).)
E. The Contractor shall conduct performance monitoring activities throughout
the Contractor's operations. These activities shall include, but not be
limited to, member beRefiGiary and system outcomes, utilization
management, utilization review, provider appeals, credentialing and
monitoring, and resolution of member "er grievances.
F. The Contractor shall have mechanisms to detect both underutilization of
services and overutilization of services. (42 C.F.R. § 438.330(b)(3).)
County of Fresno
22-20101 Al
Page 2 of 7
Exhibit A— Attachment 5
QUALITY IMPROVEMENT SYSTEM
G. The Contractor shall implement mechanisms to assess member
be"' a;�/family satisfaction. The Contractor shall assess member
"eRa;�/family satisfaction by:
1) Surveying member beRefiGiary/family satisfaction with the
Contractor's services at least annually;
2) Evaluating member benefiGiary grievances, appeals and State
Hearings at least annually; and
3) Evaluating requests to change persons providing services at least
annually.
4) The Contractor shall inform providers of the results of member
beR ary/family satisfaction activities.
H. The Contractor shall implement mechanisms to monitor the safety and
effectiveness of medication practices. The monitoring mechanism shall be
under the supervision of a person licensed to prescribe or dispense
prescription drugs. Monitoring shall occur at least annually.
I. The Contractor shall implement mechanisms to address meaningful
clinical issues affecting members benefiGiaFioo system-wide.
J. The Contractor shall implement mechanisms to monitor appropriate and
timely intervention of occurrences that raise quality of care concerns. The
Contractor shall take appropriate follow-up action when such an
occurrence is identified. The results of the intervention shall be evaluated
by the Contractor at least annually.
K. The Contractor's QAPI Program shall include Performance Improvement
Projects as specified in paragraph 5.
County of Fresno
22-20101 Al
Page 3 of 7
Exhibit A— Attachment 5
QUALITY IMPROVEMENT SYSTEM
2. Quality Improvement (QI) Work Plan
C. The Contractor shall have a Quality Improvement (QI) Work Plan covering
the current contract cycle with documented annual evaluations and
documented revisions as needed. The QI Work Plan shall include:
1) Evidence of the monitoring activities including, but not limited to,
review of member "ery grievances, appeals, expedited
appeals, State Hearings, expedited State Hearings, provider
appeals, and clinical records review as required by Cal. Code
Regs., tit. 9, § 1810.440(a)(5) and 42 C.F.R. § 438.416(a);
2) Evidence that QI activities, including performance improvement
projects, have contributed to meaningful improvement in clinical
care and member beRefiGiary service;
3) A description of completed and in-process QI activities, including
performance improvement projects. The description shall include:
a. Monitoring efforts for previously identified issues, including
tracking issues over time;
b. Objectives, scope, and planned QI activities for each year;
and,
C. Targeted areas of improvement or change in service delivery
or program design.
4) A description of mechanisms the Contractor has implemented to
assess the accessibility of services within its service delivery area.
This shall include goals for responsiveness for the Contractor's 24-
hour toll-free telephone number, timeliness for scheduling of routine
appointments, timeliness of services for urgent conditions, and
access to after-hours care; and
5) Evidence of compliance with the requirements for cultural
competence and linguistic competence specified in Attachments 7
and 11 .
County of Fresno
22-20101 Al
Page 4 of 7
Exhibit A— Attachment 5
QUALITY IMPROVEMENT SYSTEM
3. Quality Improvement (QI) Committee and Program
A. The Contractor's QI program shall monitor the Contractor's service
delivery system with the aim of improving the processes of providing care
and better meeting the needs of its members b8Refiniarioo
B. The Contractor shall establish a QI Committee to review the quality of
specialty mental health services provided to members benefiniarioc. The
QI Committee shall recommend policy decisions; review and evaluate the
results of QI activities, including performance improvement projects;
institute needed QI actions; ensure follow-up of QI processes; and
document QI Committee meeting minutes regarding decisions and actions
taken.
C. The QI Program shall be accountable to the Contractor's Director as
described in Cal. Code Regs., tit. 9, § 1810.440(a)(1).
D. Operation of the QI program shall include substantial involvement by a
licensed mental health professional. (Cal. Code. Regs., tit. 9, §
1810.440(a)(4).)
E. The QI Program shall include active involvement in the planning, design
and execution of the QI Program by the Contractor's practitioners and
providers, members benefiGiarioc who have accessed specialty mental
health services through the Contractor, family members, legal
representatives, or other persons similarly involved with members
beRefiniories as described in Cal. Code. Regs., tit. 9, § 1810.440(a)(2)(A-
C).
F. QI activities shall include:
1) Collecting and analyzing data to measure against the goals, or
prioritized areas of improvement that have been identified;
2) Identifying opportunities for improvement and deciding which
opportunities to pursue;
County of Fresno
22-20101 Al
Page 5 of 7
Exhibit A— Attachment 5
QUALITY IMPROVEMENT SYSTEM
3) Identifying relevant committees internal or external to the
Contractor to ensure appropriate exchange of information with the
QI Committee;
4) Obtaining input from providers, members beRefiGiari and family
members in identifying barriers to delivery of clinical care and
administrative services;
5) Designing and implementing interventions for improving
performance;
6) Measuring effectiveness of the interventions;
7) Incorporating successful interventions into the Contractor's
operations as appropriate; and
8) Reviewing member beRefiGiaFy grievances, appeals, expedited
appeals, State Hearings, expedited State Hearings, provider
appeals, and clinical records review as required by Cal. Code
Regs., tit. 9, § 1810.440(a)(5).
4. External Quality Review
The Contractor shall undergo annual, external independent reviews of the
quality, timeliness, and access to the services covered under this Contract, which
are conducted pursuant to Subpart E of Part 438 of the Code of Federal
Regulations. (42 C.F.R. §§ 438.350(a) and 438.320)
5. Performance Improvement Projects
A. The Contractor shall conduct a minimum of two Performance
Improvement Projects (PIPs) per year, including any PIPs required by
DHCS or CMS. DHCS may require additional PIPs. One PIP shall focus
on a clinical area and one on a non-clinical area. (42 C.F.R. §
438.330(b)(1) and (d)(1).) Each PIP shall:
1) Be designed to achieve significant improvement, sustained over
time, in health outcomes and member "ery satisfaction;
County of Fresno
22-20101 Al
Page 6 of 7
Exhibit A— Attachment 5
QUALITY IMPROVEMENT SYSTEM
2) Include measurement of performance using objective quality
indicators;
3) Include implementation of interventions to achieve improvement in
the access to and quality of care;
4) Include an evaluation of the effectiveness of the interventions
based on the performance measures collected as part of the PIP;
and,
5) Include planning and initiation of activities for increasing or
sustaining improvement. (42 C.F.R. § 438.330(d)(2).)
B. The Contractor shall report the status and results of each performance
improvement project to the Department as requested, but not less than
once per year. (42 C.F.R. § 438.330(d)(3).)
6. Practice Guidelines
A. The Contractor shall adopt practice guidelines. (42 C.F.R. § 438.236(b)
and Cal. Code Regs., tit. 9, § 1810.326)
B. Such guidelines shall meet the following requirements:
1) They are based on valid and reliable clinical evidence or a
consensus of health care professionals in the applicable field;
2) They consider the needs of the members beRefiGiario�
3) They are adopted in consultation with network providers; and
4) They are reviewed and updated periodically as appropriate. (42
C.F.R. § 438.236(b).)
C. The Contractor shall disseminate the guidelines to all affected providers
and, upon request, to members benefiGiari and potential members
bene .aFie& (42 C.F.R. § 438.236(c).)
D. The Contractor shall take steps to assure that decisions for utilization
management, member benefiGiary education, coverage of services, and
County of Fresno
22-20101 Al
Page 7 of 7
Exhibit A— Attachment 5
QUALITY IMPROVEMENT SYSTEM
any other areas to which the guidelines apply shall be consistent with the
guidelines.
(42 C.F.R. § 438.236(d).)
County of Fresno
22-20101 Al
Page 1 of 3
Exhibit A— Attachment 6
UTILIZATION MANAGEMENT PROGRAM
1. Utilization Management
A. The Contractor shall operate a Utilization Management Program that is
responsible for assuring that members b8Refiniarioc have appropriate
access to specialty mental health services as required in Cal. Code Regs.,
tit. 9, section 1810.440(b)(1)-(3).
B. The Utilization Management Program shall evaluate medical necessity,
appropriateness and efficiency of services provided to Medi-Cal members
beRefiG.aries prospectively or retrospectively.
C. Compensation to individuals or entities that conduct utilization
management activities must not be structured so as to provide incentives
for the individual or entity to deny, limit, or discontinue medically
necessary services to any member berry. (42 C.F.R. § 438.210(e).)
D. The Contractor may place appropriate limits on a service based on criteria
applied under the State Plan, such as criteria for access to SMHS and for
the purpose of utilization control, provided that the services furnished are
sufficient in amount, duration and scope to reasonably achieve the
purpose for which the services are furnished. (42 C.F.R. §
438.210(a)(4)(i), (ii)(A).)
E. The Contractor shall not impose quantitative treatment limitations,
aggregate lifetime or annual dollar limits as defined in 42 C.F.R. 438.900,
for any member beRefiGiary receiving specialty mental health services.
F. The Contractor shall not impose non-quantitative treatment limitations for
specialty mental health services in any benefit classification (i.e., inpatient
and outpatient) unless the Contractor's policies and procedures have been
determined by the Department to comply with Title 42 of the Code of
Federal Regulations, subpart K. (42 C.F.R. § 438.910(d).)
G. The Contractor shall submit to the Department, upon request, any policies
and procedures or other documentation necessary for the State to
establish and demonstrate compliance with Title 42 of the Code of Federal
Regulations, part 438, subpart K, regarding parity in mental health and
substance use disorder benefits.
County of Fresno
22-20101 Al
Page 2 of 3
Exhibit A— Attachment 6
UTILIZATION MANAGEMENT PROGRAM
2. Service Authorization
A. Contractor shall implement mechanisms to assure authorization decision
standards are met in accordance with Behavioral Health Information
Notices (BHINs) 22-016 and 22-017, or any subsequent Departmental
notices issued to address parity in mental health and substance use
disorder benefits subsequent to the effective date of this contract, and any
applicable state and federal regulations. (42 C.F.R. § 438.910(d).) The
Contractor shall:
1) Have in place, and follow, written policies and procedures for
processing requests for initial and continuing authorizations of
services. (42 C.F.R. § 438.210(b)(1).)
2) Have mechanisms in effect to ensure consistent application of
review criteria for authorization decisions and shall consult with the
requesting provider when appropriate. (42 C.F.R. § 438.210(b)(2)(i-
ii).)
3) Have any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less
than requested be made by a health care professional who has
appropriate clinical expertise in addressing the member's
benef!Giary-°& behavioral health needs. (42 C.F.R. § 438.210(b)(3).)
4) Notify the requesting provider and give the member benefiGiary
written notice of any decision by the Contractor to deny a service
authorization request, or to authorize a service in an amount,
duration, or scope that is less than requested. (42 C.F.R. §
438.210(c)) The member's beRefiGiar notice shall meet the
requirements in Attachment 12, Section 10, paragraph A and
Section 9, paragraph J and be provided within the timeframes set
forth in Attachment 12, Section 10, paragraph B and Section 9,
paragraph H.
B. The Contractor shall comply with authorization timeframes in accordance
with BHINs 22-016 and 22-017, or any subsequent Departmental notices
issued to address parity in mental health and substance use disorder
benefits subsequent to the effective date of this contract, as well as any
applicable state and federal regulations. (42 C.F.R. § 438.910(d).)
County of Fresno
22-20101 Al
Page 3 of 3
Exhibit A— Attachment 6
UTILIZATION MANAGEMENT PROGRAM
C. For cases in which a provider indicates, or the Contractor determines, that
following the standard timeframe could seriously jeopardize the member's
beReflGIaFY'S life or health or ability to attain, maintain, or regain maximum
function, the Contractor shall make an expedited authorization decision
and provide notice as expeditiously as the member's b8RefiGiaryis health
condition requires and no later than 72 hours after receipt of the request
for service. The Contractor may extend the 72-hour time period by up to
14 calendar days if the member "ery requests an extension, or if
the Contractor justifies (to the Department upon request), and documents,
a need for additional information and how the extension is in the
member's beRefiniary-I interest. (42 C.F.R. § 438.210(d)(2))
D. The Contractor shall act on an authorization request for treatment for
urgent conditions within one hour of the request. (Cal. Code Regs., tit. 9,
§§ 1810.253 1810.405, subd. (c)).
E. The Contractor shall not require prior authorization for an emergency
admission for psychiatric inpatient hospital services, whether the
admission is voluntary or involuntary. (Cal. Code Regs., tit. 9, §§
1820.200(d) and 1820.225).
D. The Contractor shall define service authorization request in a manner that
at least includes a member's benefiGiaryis. request for the provision of a
service. (42 C.F.R. § 431.201)
County of Fresno
22-20101 Al
Page 1 of 5
Exhibit A— Attachment 7
ACCESS AND AVAILABILITY OF SERVICES
1. Member Benef maFy Enrollment
A. Medi-Cal eligible members benefiniarioc are automatically enrolled in the
single MHP in their county. (1915(b) waiver, § A, part I, para. C, p. 31.)
B. The Contractor shall be responsible for providing or arranging and paying
for specialty mental health services for Medi-Cal eligible individuals in its
county who require an assessment or meet criteria for access to specialty
mental health services. (Cal. Code Regs. tit. 9, §1810.228.) The
Contractor shall accept these individuals in the order in which they are
referred (including self-referral) without restriction (unless authorized by
CMS), up to the limits set under this Contract. (42 C.F.R. § 438.3(d)(1).)
C. The Contractor shall not, on the basis of health status or need for health
care services, discriminate against Medi-Cal eligible individuals in its
county who require an assessment or meet criteria for access to specialty
mental health services. (42 C.F.R. § 438.3(d)(3).)
D. The Contractor shall not unlawfully discriminate against Medi-Cal eligible
individuals in its county who require an assessment or meet criteria for
access to specialty mental health services on the basis of race, color,
national origin, sex, sexual orientation, gender, gender identity, religion,
marital status, ethnic group identification, ancestry, age, medical condition,
genetic information, mental disability, or physical disability, and will not
use any policy or practice that has the effect of discriminating on the basis
of race, color, national origin, sex, sexual orientation, gender, gender
identity, religion, marital status, ethnic group identification, ancestry, age,
medical condition, genetic information, mental disability, or physical
disability. (42 U.S.C. § 18116; 42 C.F.R. § 438.3(d)(4); 45 C.F.R. § 92.2;
Gov. Code § 11135(a); W&I Code § 14727(a)(3).)
2. Cultural Competence
A. The Contractor shall participate in the State's efforts to promote the
delivery of services in a culturally competent manner to all members
benefiniaries including those with limited English proficiency and diverse
cultural and ethnic backgrounds, disabilities, and regardless of gender,
sexual orientation, or gender identity. (42 C.F.R. § 438.206(c)(2).)
County of Fresno
22-20101 Al
Page 2 of 5
Exhibit A— Attachment 7
ACCESS AND AVAILABILITY OF SERVICES
B. The Contractor shall comply with the provisions of the Contractor's
Cultural Competence Plan submitted and approved by the Department.
The Contractor shall update the Cultural Competence Plan and submit
these updates to the Department for review and approval annually. (Cal.
Code Regs., tit. 9, § 1810.410, subds. (c)-(d).)
3. Out-of-Network Services
A. The Contractor's provider network is unable to provide necessary services
within the time, distance, and timely access standards, covered under
this Contract, to a particular member beRefiGiary, the Contractor shall
allow members to access the services and adequately and timely cover
the services out-of-network, for as long as the Contractor's provider
network is unable to provide them and in accordance with state and
federal law, this contract, and Department information notices,
including BHIN 21-008, and any subsequent notices. (42 C.F.R. §
438.206(b)(4).)
B. In cases where an out-of-network provider is not available within the
time and distance standards, Contractor shall arrange for telehealth
or transportation to an in-person visit. Contractor shall ensure that
members have the right to an in-person visit if they do not want to
accept a telehealth visit. Contractor shall ensure that services
rendered by out-of-network providers, including those provided
within a Department approved alternative access standard, comply
with timely access standards.
C. The Contractor shall require that out-of-network providers coordinate
authorization and payment with the Contractor. The Contractor must
ensure that the cost to the member "ery for services provided out-
of-network pursuant to an authorization is no greater than it would be if the
services were furnished within the Contractor's network, consistent with
Cal. Code Regs., tit. 9, section 1810.365. (42 C.F.R. § 438.206(b)(5).)
D. The Contractor shall comply with the requirements of Cal. Code Regs., tit.
9, section 1830.220 regarding providing members beRefi^iarioo access to
out-of-network providers when a provider is available in Contractor's
network.
County of Fresno
22-20101 Al
Page 3 of 5
Exhibit A— Attachment 7
ACCESS AND AVAILABILITY OF SERVICES
E. Pursuant to Department guidance, the Contractor shall submit to the
Department for approval policies and procedures regarding authorization
of out-of-network services to establish compliance with title 42 of the Code
of Federal Regulations, section 438.910(d)(3).
4. Foster Children Placed Out-of-County
A. IR The Contractor shall authorize, pay, provide or arrange for
medically necessary specialty mental health services for foster
children placed outside of their counties of origin in accordance with
W&I Code section 14717.1 and 14717.2 and pursuant to Department
information notices, including the (;ontrantor shall he res Ponsible to
autherize, pay, nreyide er arrange fer mediGa�no E -csmry cn oniiurlty
mental health seFVines fnr foster nhildren residing in the Gontrantor's
nni Rty e P r!whe are lane ei t i itside of+heir nonties of origin, i finless
Press MPtiVe transfer WaiVer is in Plane
B. The Contractor,^ 'nshall follow ^eRtal Heat anee Use
Dim Disorder Ii rfeffna iriNeRGes npertaiR i nn tPresumptive TraRsfe�
for Foster (children DlaGed O Ut Of Ge inty Mental Health and Substance
Use Disorder (MHSUDS) IN 17-032, 18-027, BHIN 19-041, and any
subsequent Information Notices. These Information Notices include
standardized templates that the Contractor may use or adapt to the
Contractor's needs.
G. CC)RtraGter shall accept a PceOMpleteda-rneRtal health asses-srn Rt frvrmi-r
th�JteFGhil�Cni inty of origin meRtalhealth plan The G(DTtra r may
r•opdi int additional assessmepts if the foster nhild's needs nhanoe or an
updated assessment is needed to determine the nhild's needs and identify
the needed treatment and seFVines to address these needs
.When a request for a presumptive transfer�ver�een made fer a
foster nhild from the GGRtraGtr)r'o nee Rty who is beiRg Planed eutside of
the Gontrantor's not IPty the (;entrantor shall noPtiR fie to provide medically
e
penessary specialty mental health seFViGes to that foster nhild until a
presumptive transfer waiver determinatien has been made
E. The GeTtFao4�hall he respensible te authorize, pay, provide or arrange
fnr medically penessary specialty mental health services for foster nhildren
County of Fresno
22-20101 Al
Page 4 of 5
Exhibit A— Attachment 7
ACCESS AND AVAILABILITY OF SERVICES
nrigiRally from the GGRtrontor'c not Rty who are residing of 1tside of the
( E)Rtrontor'c not Rtye if a PPS imotiVe tFaRQfor WaiVeF is in PlaGe
5. Children in Adoption Assistance Program (AAP) and Kinship Guardian
Assistance Payment (Kin-GAP)
A. The Contractor shall provide or arrange for the provision of medically
necessary specialty mental health services to a child in the Adoption
Assistance Program (AAP) residing within their adoptive parents' county of
residence in the Contractor's county. These services are to be provided in
the same way as the Contractor would provide services to any other child
for whom the Contractor's county is listed as the county of responsibility
on the Medi-Cal Eligibility Data System (MEDS). When treatment
authorization requests are required, the Contractor shall be responsible for
submitting treatment authorization requests to the mental health plan in
the child's county of origin. (W&I Code § 16125.)
B. The Contractor shall provide or arrange for the provision of medically
necessary specialty mental health services to a child in the Kinship-
Guardian Assistance Program (Kin-GAP) residing within their legal
guardian's county of residence in the Contractor's county. These services
are to be provided in the same way that the Contractor would provide
services to any other child for whom the Contractor GGunty is listed as the
county of responsibility on the MEDS. When treatment authorization
requests are required, the Contractor shall be responsible for submitting
treatment authorization requests to the mental health plan in the child's
county of origin. (W&I Code § 11376.)
C. When the Contractor is the mental health plan in the county of origin for a
child in AAP residing out-of-county with their adoptive parents (W&I Code
§ 16125) or a child in Kin-GAP residing out-of-county with their legal
guardian (W&I Code § 11376) the Contractor shall be responsible for
authorization and reauthorization of services for the child utilizing an
expedited treatment authorization process that meets the authorization
requirements set forth in MHSUDS Information Notice 22-016 and any
applicable Departmental notices issued after the effective date of this
contract.
County of Fresno
22-20101 Al
Page 5 of 5
Exhibit A— Attachment 7
ACCESS AND AVAILABILITY OF SERVICES
D. The Contractor shall comply with timelines specified in Cal. Code Regs.,
tit. 9, § 1830.220(b)(4)(A)(1-3) and requirements set forth in MHSUDS
Information Notice 22-016 and any applicable Departmental notices
issued after the effective date of this contract, when processing or
submitting authorization requests for children in AAP, or Kin-GAP, living
outside their county of origin.
6. American Indian/Alaskan Native fndian Members Benef:^;,r:o�
A. The Contractor shall permit American Indian/Alaskan Native (AI/AN)
members aR lRdiaR beRefiniary whe is eligi to receive services from any
Indian health care provider (IHCP) participating as a network provider, to
choose that IHCP as their provider, as long as that provider has capacity to
provide the services. MHPs must reimburse MHP-certified IHCPs for the
provision of these services to AI/AN Medi-Cal members whether or not
the IHCP has a current contract with the member's county of
responsibility. (42 C.F.R. § 438.14(b)(2),(4).)
B. The Contractor shall demonstrate it has sufficient IHCPs participating in its
provider network to ensure timely access to services available under the
contract from such providers for AI/AN members lRdiaR beRefiGiaries who
are eligible to receive services. (42 C.F.R. § 438.14(b)(1).)
C. The Contractor shall document good-faith efforts to contract with all IHCPs in
the Contractor's county. If the Contractor does not contract with a IHCP in the
Contractor's county, the Contractor must submit a written explanation to the
Department of why it failed to contract with that IHCP, with supporting
documentation as provided for in BHIN 21 023 23-041.
D. The Contractor shall permit Indian members beRefiniarioc to obtain covered
services from out-of-network IHCPs if the members beRefiniarioc are
otherwise eligible to receive such services. (42 C.F.R. § 438.14(b)(4).) The
Contractor shall permit an out-of-network IHCP to refer an Indian member
hor, ;� to a network provider. (42 C.F.R. § 438.14(b)(6).)
County of Fresno
22-20101 Al
Page 1 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
1. Enrollment and Screening
A. The Contractor shall ensure that all network providers are enrolled with
the state as Medi-Cal providers consistent with the provider disclosure,
screening, and enrollment requirements of 42 Code of Federal
Regulations part 455, subparts B and E. (42 C.F.R. § 438.608(b).)
B. The Contractor may execute network provider agreements, pending the
outcome of screening, enrollment, and revalidation, of up to 120 days but
must terminate a network provider immediately upon determination that
the network provider cannot be enrolled, or the expiration of one 120-day
period without enrollment of the provider, and notify affected members
beRefiG.aries. (42 C.F.R. § 438.602(b)(2).)
2. Assessment of Capacity
A. The Contractor shall implement mechanisms to assess the capacity of
service delivery for its members beRefiGiari . This includes monitoring
the number, type, and geographic distribution of mental health services
within the Contractor's delivery system.
B. The Contractor shall implement mechanisms to assess the accessibility of
services within its service delivery area. This shall include the
assessment of responsiveness of the Contractor's 24-hour toll-free
telephone number, timeliness of scheduling routine appointments,
timeliness of services for urgent conditions, and access to after-hours
care.
3. Network Adequacy
A. The Contractor shall ensure that all services covered under this Contract
are available and accessible to members benefiGiar! in a timely manner
and without utilizing waitlists (42 C.F.R. § 438.206(a)).
B. Maintain and monitor a network of appropriate providers that is supported
by written agreements for subcontractors and that is sufficient to provide
adequate access to all services covered under this contract for all
members benefiGiari , including those with limited English proficiency or
physical or mental disabilities. The Contractor shall ensure that network
providers provide physical access, reasonable accommodations, and
County of Fresno
22-20101 Al
Page 2 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
accessible equipment for Medi-Cal members beR8fi^iaPi with physical
or mental disabilities. (42 C.F.R. § 438.206(b)(1) and (c)(3).)
C. The Contractor shall adhere to, in all geographic areas within the county,
the time and distance standards for adult and pediatric mental health
providers, as specified in BHIN 21-023 and its enclosures, or in
subsequent guidance issued by the Department. (42 C.F.R. § 438.68(a),
(b)(1)(iii), (3), 438.206(a); W&I Code § 14197.)
D. The Contractor may submit to the Department a request for Alternate
Access Standards. The Department will evaluate requests and grant
appropriate exceptions to the state developed standards, as specified in
BHIN 21-023 and its enclosures, or in subsequent guidance issued by the
Department. (42 C.F.R. § 438.68(a), (d), 438.206(a); W&I Code § 14197).
E. The Contractor shall comply with all network adequacy standards
developed by the Department to implement 42 C.F.R. section 438.68,
438.206, and 438.207, including time and distance standards, timely
access, capacity and composition standards, and other network capacity
requirements, as specified in BHIN 21-023 and its enclosures, or in
subsequent guidance issued by the Department.
4. Timely Access
A. Timely Access. In accordance with 42 C.F.R. section 438.206(c)(1), the
Contractor shall:
1) Meet and require4ts network providers to meet standards for timely
access to care and services, without utilizing waitlists taking into
account the urgency of need for services, pursuant to W&I Code
section 14197(d), as specified in BHIN 23-041 21 023 and its
enclosures, or in subsequent, guidance issued by the Department.
a) Contractor shall ensure that members are offered
appointments within the following timeframes:
i. Urgent care appointment for services that
do not require prior authorization: within 48
hours of request.
County of Fresno
22-20101 Al
Page 3 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
ii. Urgent care appointment for services that
require prior authorization: within 96 hours
of request.
iii. Nonurgent appointments with a
psychiatrist: within fifteen (15) business
days of request.
iv. Nonurgent appointments with a
nonphysician mental health care provider:
within ten (10) business days of request.
V. Nonurgent follow-up appointment with a
nonphysician mental health care provider:
within ten (10) business days of the prior
appointment for members undergoing a
course of treatment for an ongoing mental
health condition. This does not limit
coverage for nonurgent follow-up
appointments with a nonphysician mental
health care provider to once every ten (10)
business days.
b) Urgent care appointments must be offered when a
member has a condition that requires prompt
attention, such that they face an imminent and
serious threat to their health, including, but not
limited to, the potential loss of life, limb, or other
major bodily function, or the normal timeframe for
the decision-making process would be
detrimental to the member's life or health or could
jeopardize the member's ability to regain
maximum function. In accordance with Cal. Code
Regs., tit. 9, section 1810.405, subdivision (c),
Contractor shall have a statewide toll-free
telephone number available 24 hours a day, seven
days per week, to act on payment authorization
requests for services to treat a member's urgent
condition and shall respond to these requests
within one hour of the request.
County of Fresno
22-20101 Al
Page 4 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
c) The waiting time for a particular appointment may
be extended if the referring or treating licensed
health care provider, or the health professional
providing triage or screening services, as
applicable, acting within the scope of their
practice and consistent with professionally
recognized standards of practice, has determined
and noted in the relevant record that a longer
waiting time will not have a detrimental impact on
the health of the member.
d) Appointments for periodic follow-up care and
preventive services to prevent and detect disease,
illness, injury, or other health conditions may be
scheduled in advance, consistent with
professionally recognized standards of practice
as determined by the treating licensed health care
provider acting within the scope of their practice.
2) Comply with the fimoliRess stag Ards speGified in Col Coale
Qegs., tot. 9, scEt♦GR 1910.405(G) and Welf. S2. IRSt. Code § 14717.1 .
Thorn stag arrds apply to out of plan serViGes as well as in plan
coriiroc
�.T
2) Require of bGORtron4oil network providers to have hours of
operation during which services are provided to Medi-Cal members
beRefiniorioc that are no less than the hours of operation during
which the provider offers services to non-Medi-Cal members
beRefiniarioc If the provider only serves Medi-Cal members
benefiniarioc the Contractor shall require that hours of operation
are comparable to the hours the provider makes available for Medi-
Cal services that are not covered by the Contractor, or another
Mental Health Plan.
3) Make services available to members honofiniarioc 24 hours a day,
7 days a week, when medically necessary.
4) Establish mechanisms to ensure that network providers comply
with the timely access requirements.
County of Fresno
22-20101 Al
Page 5 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
5) Monitor network providers regularly to determine compliance with
timely access requirements.
6) Take corrective action if a network provider fails to comply with
there is a failure +„ G.,rr Ply with timely access requirements by-a
rietWE)Fk PFE)Vide
5. Documentation of Network Adequacy
A. The Contractor shall give assurances to the Department and provide
supporting documentation that demonstrates Contractor has the capacity
to serve the expected enrollment in its service area in accordance with
BHIN 21 023 23-041 and its enclosures, or in subsequent guidance issued
by the Department. (42 C.F.R. § 438.207(a); W&I Code § 14197(f).)
B. The Contractor shall submit documentation to the Department, as
specified in BHIN 21-023 and its enclosures, or in subsequent guidance
issued by the Department to demonstrate that it complies with the
following requirements:
1) Offers an appropriate range of specialty services that are adequate
for the anticipated number of members benefiniarioc for the service
area.
2) Maintains a network of providers that is sufficient in number, mix,
and geographic distribution to meet the needs of the anticipated
number of members beRefiGiarioc in the service area. (42 C.F.R. §
438.207(b).)
C. The Contractor shall submit the documentation at the times specified in
BHIN 21-023 and its enclosures, or in subsequent guidance issued by the
Department, but no less frequently than the following:
1) At the time it enters into this Contract with the Department;
2) On an annual basis; and
3) Within 10 business days of a significant change in the Contractor's
operations that would render the Contractor non-compliant with
standards for network adequacy and capacity including, but not
limited to, the following types of changes:
County of Fresno
22-20101 Al
Page 6 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
a) Changes in services;
b) Changes in benefits;
c) Changes in geographic service area;
d) Changes in the composition of or payments to the Contractor's
provider network; or
e) Enrollment of a new population in the Contractor's county. (42
C.F.R. § 438.207(c).);
f) The Contractor is required to notify DHCS by email of one of
the listed changes at MHSDFinalRule@dhcs.ca.gov.
D. The Contractor shall include details regarding the change and the
Contractor's plans to ensure members beRefiGiar; continue to have
access to adequate services and providers.
6. Choice of Provider
The Contractor shall provide a member's benefiGiaryis. choice of the person
providing services to the extent possible and appropriate consistent with Cal.
Code Regs., tit. 9, §1830.225 and 42 Code of Federal Regulations part 438.3(I).
7. Provider Selection
A. The Contractor shall have written policies and procedures for selection
and retention of providers. (42 C.F.R. § 438.214(a).)
B. The Contractor's policies and procedures for selection and retention of
providers must not discriminate against particular providers that serve
high-risk populations or specialize in conditions that require costly
treatment. (42 C.F.R. §§ 438.12(a)(2), 438.214(c).)
County of Fresno
22-20101 Al
Page 7 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
C. In all subcontracts with network providers, the Contractor must follow the
Department's uniform credentialing and re-credentialing policy. The
Contractor must follow a documented process for credentialing and re-
credentialing of network providers. (42 C.F.R. §§ 438.12(a)(2),
438.214(b).)
D. The Contractor shall not employ or subcontract with providers excluded
from participation in Federal health care programs under either section
1128 or section 1128A of the Act. (42 C.F.R. § 438.214(d).)
E. The Contractor may not discriminate in the selection, reimbursement, or
indemnification of any provider who is acting within the scope of their
license or certification under applicable state law, solely on the basis of
that license or certification. (42 C.F.R. § 438.12(a)(1).)
F. The Contractor shall give practitioners or groups of practitioners who apply
to be MHP contract providers and with whom the MHP decides not to
contract written notice of the reason for a decision not to contract. (42
C.F.R. § 438.12(a)(1).)
G. Paragraphs A-F, above, may not be construed to:
1) Require the Contractor to subcontract with providers beyond the
number necessary to meet the needs of its members beRefiGiario�
2) Preclude the Contractor from using different reimbursement
amounts for different specialties or for different practitioners in the
same specialty; or
3) Preclude the Contractor from establishing measures that are
designed to maintain quality of services and control costs and are
consistent with its responsibilities to members beRefiGiarioc. (42
C.F.R. § 438.12(b).)
H. Upon request, the Contractor shall demonstrate to the Department that its
providers are credentialed as required by paragraph C. (42 C.F.R. §
438.206(b)(6)
County of Fresno
22-20101 Al
Page 8 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
I. The Contractor shall establish individual, group and organizational
provider selection criteria as provided for in Cal. Code Regs., tit. 9, section
1810.435.
J. The Contractor shall only use licensed, registered, or waivered providers
acting within their scope of practice for services that require a license,
waiver, or registration. (Cal. Code Regs., tit. 9, § 1840.314(d).)
K. The Contractor is not located outside of the United States. (42 C.F.R. §
602(i).)
8. Provider Certification
A. The Contractor shall comply with Cal. Code Regs., tit. 9, section
1810.435, in the selection of providers and shall review its providers for
continued compliance with standards at least once every three years.
B. The Contractor shall comply with the provisions of 42 Code of Federal
Regulations, sections parts 455.104, 455.105, 1002.203 and 1002.3,
which relate to the provision of information about provider business
transactions and provider ownership and control, prior to entering into a
contract and during certification or re-certification of the provider.
C. "Satellite site" means a site owned, leased or operated by an
organizational provider at which specialty mental health services are
delivered to members benefiGiarioo fewer than 20 hours per week, or, if
located at a multiagency site at which specialty mental health services are
delivered by no more than two employees or contractors of the provider.
D. The Contractor shall certify, or use another mental health plan's
certification documents to certify, the organizational providers that
subcontract with the Contractor to provide covered services in accordance
with Cal. Code Regs., tit. 9, section 1810.435, and the requirements
specified prior to the date on which the provider begins to deliver services
under the contract, and once every three years after that date. The on-
site review required by Cal. Code Regs., tit. 9, section 1810.435(d), as a
part of the certification process, shall be made of any site owned, leased,
or operated by the provider and used to deliver covered services to
members beRefiGiari , except that on-site review is not required for
public school or satellite sites.
County of Fresno
22-20101 Al
Page 9 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
E. The Contractor may allow an organizational provider to begin delivering
covered services to members benefiGiarioo at a site subject to on-site
review prior to the date of the on-site review, provided the site is
operational and has any required fire clearances. The earliest date the
provider may begin delivering covered services at a site subject to on-site
review is the latest of these three (3) dates: 1) the date the provider's
request for certification is received by the Department in accordance with
the Contractor's certification procedures; 2) the date the site was
operational; or 3) the date a required fire clearance was obtained. The
Contractor shall complete any required on-site review of a provider's sites
within six months of the date the provider begins delivering covered
services to members beRefiGiari at the site.
F. The Contractor may allow an organizational provider to continue delivering
covered services to members beR8fiGiar; at a site subject to on-site
review as part of the recertification process prior to the date of the on-site
review, provided the site is operational and has any required fire
clearances. The Contractor shall complete any required on-site review of
a provider's sites within six months of the date the recertification of the
provider is due.
G. The Contractor and/or the Department shall each verify through an on-site
review that-
1) The organizational provider possesses the necessary license to
operate, if applicable, and any required certification.
2) The space owned, leased or operated by the provider and used for
services or staff meets local fire codes.
3) The physical plant of any site owned, leased, or operated by the
provider and used for services or staff is clean, sanitary, and in
good repair.
4) The organizational provider establishes and implements
maintenance policies for any site owned, leased, or operated by the
provider and used for services or staff to ensure the safety and
well-being of members benefiGiarioo and staff.
County of Fresno
22-20101 Al
Page 10 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
5) The organizational provider has a current administrative manual
which includes: personnel policies and procedures, general
operating procedures, service delivery policies, any required state
or federal notices (DRA), and procedures for reporting unusual
occurrences relating to health and safety issues.
6) The organizational provider maintains client records in a manner
that meets the requirements of the Contractor, the requirements of
Attachment 10; and applicable state and federal standards.
7) The organizational provider has sufficient staff to allow the
Contractor to claim federal financial participation (FFP) for the
services that the organizational provider delivers to members
beRefiniarioc as described in Cal. Code Regs., tit. 9, sections
1840.344 through 1840.358, as appropriate and applicable.
8) The organizational provider has written procedures for referring
individuals to a psychiatrist when necessary, or to a physician, if a
psychiatrist is not available.
9) The organizational provider's head or chief of service, as defined
Cal. Code Regs., tit. 9, sections 622 through 630, is a licensed
mental health professional or other appropriate individual as
described in these sections.
10) For organizational providers that provide or store medications, the
provider stores and dispenses medications in compliance with all
pertinent state and federal standards. In particular:
a) All drugs obtained by prescription are labeled in compliance
with federal and state laws. Prescription labels are altered
only by persons legally authorized to do so.
b) Drugs intended for external use only and food stuffs are
stored separately from drugs intended for internal use.
c) All drugs are stored at proper temperatures: room
temperature drugs at 59-86 degrees Fahrenheit and
refrigerated drugs at 36-46 degrees Fahrenheit.
d) Drugs are stored in a locked area with access limited to
those medical personnel authorized to prescribe, dispense
County of Fresno
22-20101 Al
Page 11 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
or administer medication.
e) Drugs are not retained after the expiration date.
Intramuscular multi-dose vials are dated and initialed when
opened.
f) A drug log is maintained to ensure the provider disposes of
expired, contaminated, deteriorated and abandoned drugs in
a manner consistent with state and federal laws.
g) Policies and procedures are in place for dispensing,
administering and storing medications.
H. For organizational providers that provide day treatment intensive or day
rehabilitation, the provider has a written description of the day treatment
intensive and/or day rehabilitation program that complies with Attachment
2, Section 3 of this exhibit.
I. When an on-site review of an organizational provider would not otherwise
be required and the provider offers day treatment intensive and/or day
rehabilitation, the Contractor or the Department, as applicable, shall, at a
minimum, review the provider's written program description for compliance
with the requirements of Attachment 2, Section 3 of this exhibit.
J. On-site review is required for hospital outpatient departments which are
operating under the license of the hospital. Services provided by hospital
outpatient departments may be provided either on the premises or off-site.
K. On-site review is not required for primary care and psychological clinics,
as defined in Health and Safety Code section 1204.1 and licensed under
the Health and Safety Code. Services provided by the clinics may be
provided on the premises in accordance with the conditions of the clinic's
license.
L. When on-site review of an organizational provider is required, the
Contractor or the Department, as applicable, shall conduct an on-site
review at least once every three years. Additional certification reviews of
organizational providers may be conducted by the Contractor or
Department, as applicable, at its discretion, if-
1) The provider makes major staffing changes.
County of Fresno
22-20101 Al
Page 12 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
2) The provider makes organizational and/or corporate structure
changes (example: conversion to non-profit status).
3) The provider adds day treatment or medication support services
when medications are administered or dispensed from the provider
site.
4) There are significant changes in the physical plant of the provider
site (some physical plant changes could require a new fire
clearance).
5) There is a change of ownership or location.
6) There are complaints regarding the provider.
7) There are unusual events, accidents, or injuries requiring medical
treatment for clients, staff or members of the community.
M. The Contractor shall monitor the performance of its subcontractors on an
ongoing basis for compliance with the terms of this contract and shall
subject the subcontractors' performance to periodic formal review, at a
minimum in accordance with the recertification requirements. If the
Contractor identifies deficiencies or areas for improvement, the Contractor
and the subcontractor shall take corrective action.
N. In addition, Contractor may accept the certification of a provider by
another Mental Health Plan, or by the Department, in order to meet the
Contractor's obligations under Attachment 8, Sections 7 and 8. However,
regardless of any such delegation to a subcontracting entity or acceptance
of a certification by another MHP.
9. Provider Member Benefm^ma^• Communications
A. The Contractor shall not prohibit nor otherwise restrict, a licensed,
waivered, or registered professional, as defined in Cal. Code Regs., tit. 9,
sections 1810.223 and 1810.254, who is acting within the lawful scope of
practice, from advising or advocating on behalf of a member "ery
for whom the provider is providing mental health services for any of the
following:
County of Fresno
22-20101 Al
Page 13 of 13
Exhibit A— Attachment 8
PROVIDER NETWORK
1) The member's beRefiniary-L health status, medical care, or
treatment options, including any alternative treatment that may be
self-administered;
2) Information the member beRefiniary needs in order to decide
among all relevant treatment options;
3) The risks, benefits, and consequences of receiving treatment or not
receiving treatment; and
4) The member beRefiniary-L right to participate in decisions regarding
their health care, including the right to refuse treatment, and to
express preferences about future treatment decisions. (42 C.F.R. §
438.102(a)(1).)
10. Provider Notifications
A. The Contractor shall inform providers and subcontractors, at the time they
enter into a contract, about:
1) Member BeRefiniary grievance, appeal, and State Hearing
procedures and timeframes as specified in 42 C.F.R. sections
438.400 through 438.424.
2) The member benefiniaFy-L right to file grievances and appeals and
the requirements and timeframes for filing.
3) The availability of assistance to the member benefiGiary with filing
grievances and appeals.
4) The member's benefiGiary-Ls. right to request a State Hearing after
the Contractor has made a determination on a member's
benefiniar appeal, which is adverse to the member beRefiGiary.
5) The member's benefiGiary-L& right to request continuation of
benefits that the Contractor seeks to reduce or terminate during an
appeal or State Hearing filing, if filed within the allowable
timeframes, although the member henry may be liable for the
cost of any continued benefits while the appeal or State Hearing is
pending if the final decision is adverse to the member be ary.
County of Fresno
22-20101 Al
Page 1 of 1
Exhibit A— Attachment 9
DOCUMENTATION REQUIREMENTS
1. Documentation Standards
A. The Contractor shall implement and comply with documentation standards as set
forth in guidance issued by the Department in BHIN 22 019 23-068.
County of Fresno
22-20101 Al
Page 1 of 4
Exhibit A— Attachment 10
COORDINATION AND CONTINUITY OF CARE
1. Coordination of Care
A. The Contractor shall implement procedures to deliver care to and
coordinate services for all of its members benefiniarioc. (42 C.F.R. §
438.208(b).) These procedures shall meet Department requirements and
shall do the following:
1) Ensure that each member beRefi^iary has an ongoing source of
care appropriate to their needs and a person or entity formally
designated as primarily responsible for coordinating the services
accessed by the member beR8finiar.,. The member beRefiGiary
shall be provided information on how to contact their designated
person or entity. (42 C.F.R. § 438.208(b)(1).)
2) Coordinate the services the Contractor furnishes to the member
beRefiGiary between settings of care, including appropriate
discharge planning for short term and long-term hospital and
institutional stays. Coordinate the services the Contractor furnishes
to the member beRefiGiar with the services the member
beRefiGiary receives from any other managed care organization, in
FFS Medicaid, from community and social support providers, and
other human services agencies used by its members beRefiniarioo
(42 C.F.R. § 438.208(b)(2)(i)-(iv), Cal. Code Regs., tit. 9 §
1810.415.)
3) The Contractor shall share with the Department or other managed
care entities serving the member benefiGiary the results of any
identification and assessment of that member's beRefiGiar
needs to prevent duplication of those activities. (42 C.F.R. §
438.208(b)(4).)
4) Ensure that each provider furnishing services to members
benefi^iari maintains and shares, as appropriate, a member
hor,�iary health record in accordance with professional
standards. (42 C.F.R. § 438.208(b)(5).)
5) Ensure that, in the course of coordinating care, each member's
benefiniary-' privacy is protected in accordance with all federal and
state privacy laws, including but not limited to 45 C.F.R. § 160 and
§ 164, subparts A and E, to the extent that such provisions are
applicable. (42 C.F.R. § 438.208(b)(6).)
County of Fresno
22-20101 Al
Page 2 of 4
Exhibit A— Attachment 10
COORDINATION AND CONTINUITY OF CARE
B. Consistent with the No Wrong Door policies set forth in W&I Code section
14184.402, the Contractor must cover the assessment and any SMHS
provided during the assessment period for any member "ems seeking
care, even prior to the determination of a diagnosis, even prior to the
determination of whether SMHS access criteria set forth in W&I Code section
14184.402(b)(2) are met, and even if the member be a;� is later
determined to need non-specialty mental health services (NSMHS) and/or
SUD services and is referred to the Medi-Cal Fee For Service delivery
system or a Managed Care Plan for NSMHS or to the County Department
responsible for SUD treatment. Contractor must cover SMHS even if the
service was not included in the client plan, and even if the member
"en�iary has a co-occurring mental health condition and SUD.
C. As of the effective date identified by DHCS, the Contractor must use DHCS-
approved standardized screening tools set forth in DHCS guidance
(including standardized screening tools specific for adults and standardized
screening tools specific for children and youth) to ensure members
beRefiniarioc seeking mental health services who are not currently receiving
covered SMHS or NSMHS are referred to the appropriate delivery system for
mental health services, either in the Contractor network or the Managed
Care Plan network, in accordance with the No Wrong Door policies set forth
in W&I Code section 14184.402(h).
D. If a member beRefiGiary eligible for SMHS is also eligible for NSMHS during
the course of receiving covered SMHS, the Contractor shall continue to
cover non-duplicative, Medically Necessary SMHS even if the Member is
simultaneously receiving NSMHS.
1) The Contractor must enter into a Memorandum of Understanding
with any Medi-Cal Managed Care Plan serving the Contractor's
members beRefiGiarioc to ensure Medically Necessary NSMHS
and SMHS provided concurrently are coordinated and non-
duplicative.
2) If a member "ery is receiving covered SMHS and is
determined to meet the criteria for NSMHS covered by Medi-Cal
Fee For Service and Managed Care Plans as defined by W&I Code
section 14184.402, the Contractor must use DHCS-approved
standardized transition tools set forth in DHCS guidance as
required when members beRefiniarioc who have established
relationships with contracted mental health providers experience a
change in condition requiring NSMHS. Likewise, if a member
he�iary is receiving NSMHS and is determined to meet the
County of Fresno
22-20101 Al
Page 3 of 4
Exhibit A— Attachment 10
COORDINATION AND CONTINUITY OF CARE
access criteria for SMHS as defined by W&I Code section
14184.402, the Contractor must use DHCS-approved standardized
transition tools set forth in DHCS guidance as required when
members benefiGiari who have established relationships with
NSMHS providers experience a change in condition requiring
SMHS. The Contractor must continue to cover the provision of
medically necessary SMHS provided to a member "8ry who
meets SMHS access criteria who is concurrently receiving NSMHS
when those services are not duplicative and provide coordination of
care with the Managed Care Plan.
3) The Contractor must develop and implement written policies and
procedures to ensure that members beRefiGiar; meeting criteria
for NSMHS, as indicated by a DHCS-approved standardized
transition tool (including standardized transition tools specific for
adults and standardized transition tools specific for children and
youth), are referred to the Managed Care Plan or a Fee For Service
provider offering NSMHS. Likewise, the Contractor must develop
and implement written policies and procedures to ensure that
members beRefiGiari meeting access criteria for SMHS and as
indicated by a DHCS-approved standardized transition tools
(including standardized transition tools specific for adults and
standardized transition tools specific for children and youth) are
referred by the Managed Care Plan to the Contractor.
E. The Contractor shall enter into a Memorandum of Understanding (MOU)
with any Medi-Cal managed care plan serving the Contractor's members
beRefiG Aries. The Contractor shall ensure the components of the MOU
comply with guidance issued by DHCS regarding MOU requirements. The
MOU shall address how to ensure Medically Necessary NSMHS and
SMHS provided concurrently are coordinated and non-duplicative. The
Contractor shall notify the Department in writing if the Contractor is unable
to enter into an MOU or if an MOU is terminated, providing a description of
the Contractor's good faith efforts to enter into or maintain the MOU. The
MHP shall monitor the effectiveness of its MOU with Medi-Cal managed
care plans. Should a conflict arise between the parties to the MOU, the
Contractor shall abide by the requirements in BHIN 21-034. (Cal. Code
Regs., tit. 9, § 1810.370.)
F. The Contractor shall implement a transition of care policy that is in
accordance with applicable state and federal regulations, Mental Health
and Substance Use Disorder Services Information Notice 18-059 and any
County of Fresno
22-20101 Al
Page 4 of 4
Exhibit A— Attachment 10
COORDINATION AND CONTINUITY OF CARE
Behavioral Health Information Notices issued by the Department for parity
in mental health and substance use disorder benefits subsequent to the
effective date of this contract (42 C.F.R. § 438.62(b)(1)-(2).)
County of Fresno
22-20101 Al
Page 1 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
1. Basic Requirements
A. The Contractor shall provide information in a manner and format that is
easily understood and readily accessible to members benefi^iarioo (42
C.F.R. § 438.10(c)(1).) The Contractor shall provide all written materials
for members benefi^iarioo in easily understood language, format, and
alternative formats that take into consideration the special needs of
members benefiGiarioo in compliance with 42 C.F.R. section 438.10(d)(6).
The Contractor shall inform members beRGfiGiaF9 that information is
available in alternate formats and how to access those formats in
compliance with 42 C.F.R. section 438.10.
B. The Contractor shall provide the required information in this section to
each member "ems when first receiving specialty mental health
services and upon request. (1915(b) Medi-Cal Specialty Mental Health
Services Waiver, § (2), subd. (d), at p. 26., attachments 3, 4; Cal. Code
Regs., tit. 9, § 1810.360(e).)
C. The Contractor shall operate a website that provides the content required
in this section and complies with the requirements in 42 C.F.R. section
438.10.
D. For consistency in the information provided to beneficiaries, the Contractor
shall use the Department developed definitions for managed care
terminology, including: appeal, excluded services, grievance,
hospitalization, hospital outpatient care, medically necessary, network,
non-participating provider, physician services, plan, preauthorization,
participating provider, provider, skilled nursing care, and urgent care. (42
C.F.R. § 438.10(c)(4)(i).)
E. The Contractor shall use Department developed model member
ben handbooks and member benefiGiar„ notices that describe the
transition of care policies for members benefi^iari . (42 C.F.R. §§
438.10(c)(4)(ii), 438.62(b)(3).)
County of Fresno
22-20101 Al
Page 2 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
F. Member BeRefi^iar„ information required in this section may only be
provided electronically by the Contractor if all of the following conditions
are met:
1) The format is readily accessible;
2) The information is placed in a location on the Contractor's website
that is prominent and readily accessible;
3) The information is provided in an electronic form which can be
electronically retained and printed;
4) The information is consistent with the content and language
requirements of this Attachment; and
5) The member "ems is informed that the information is
available in paper form without charge upon request and Contractor
provides it upon request within 5 business days. (42 C.F.R. §
438.10(c)(6).)
G. The Contractor shall have in place mechanisms to help members
beRefiniaries and potential members benefiGiarioc understand the
requirements and benefits of the plan. (42 C.F.R. § 438.10(c)(7).)
2. Information Provided to Members Renef.^;,r;e�
A. The Contractor shall provide information to members benefiGiarioc and
potential members beRefiniarioc including, at a minimum, all of the
following:
1) The basic features of managed care. (42 C.F.R. § 438.10(e)(2)(ii).)
2) The mandatory enrollment process. (42 C.F.R. § 438.10(e)(2)(iii).)
3) The service area covered by the Contractor. (42 C.F.R. §
438.10(e)(2)(iv).)
4) Covered benefits, including:
a. Which benefits are provided by the Contractor; and,
County of Fresno
22-20101 Al
Page 3 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
b. Which, if any, benefits are provided directly by the State.
5) The provider directory. (42 C.F.R. § 438.10(e)(2)(vi).)
6) Any cost-sharing that will be imposed by the Contractor consistent
with the State Plan. (42 C.F.R. §§ 438.10(e)(2)(vii); State Plan §
4.18.)
7) The requirements for the Contractor to provide adequate access to
covered services, including the network adequacy standards
established in 42 Code of Federal Regulations part 438.68. (42
C.F.R. § 438.10(e)(2)(viii).)
8) The Contractor's responsibilities for coordination of care. (42 C.F.R.
§ 438.10(e)(2)(ix).)
9) To the extent available, quality and performance indicators for the
Mental Health Plan, including member how satisfaction. (42
C.F.R. § 438.10(e)(2)(x).)
B. The Contractor shall make a good faith effort to give written notice of
termination of a contracted provider, to each member "er�4 who
was seen on a regular basis by the terminated provider. The notice to the
member "ery shall be provided 30 calendar days prior to the
effective date of the termination or 15 calendar days after receipt or
issuance of the termination notice, whichever is later. (42 C.F.R. §
438.10(f)(1).)
3. Language and Format
A. Nondiscrimination Requirements, Language Assistance, and
Information Access for Individuals with Limited English Proficiency
and/or Disabilities (42 CFR § 438.10; Government Code (Gov. Code) §
11135; 28 CFR §§ 35.160-35.164; 28 CFR § 36.303; 45 CFR § 92.101;
45 CFR § 92.102)
1) The Contractor shall comply with all applicable state and federal
requirements regarding nondiscrimination, language assistance,
information access, including but not limited to, the Dymally-
Alatorre Bilingual Services Act, section 1557 of the Patient
Protection and Affordable Care Act, the Americans with
Disabilities Act, and Section 504 of the Rehabilitation Act.
County of Fresno
22-20101 Al
Page 4 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
2) Nondiscrimination Notice
i. The Nondiscrimination Notice must be sent in
conjunction with each of the following significant
notices sent to members:
a. Notices of Adverse Benefit Determination.
b. Grievance acknowledgement letter.
c. Appeal acknowledgement letter.
d. Grievance resolution letter.
e. Notice of Appeal Resolution.
ii. The Contractor shall post a Department-approved
nondiscrimination notice that informs members,
potential members, and the public about
nondiscrimination, protected characteristics, and
accessibility requirements, and conveys the
Contractor's compliance with the requirements.
iii. The nondiscrimination notice shall be posted in at least
a 12-point font and be included in any documents that
are vital or critical to obtaining services and/or benefits,
and all other informational notices targeted to
beneficiaries, potential members, and the public.
Informational notices include not only documents
intended for the public, such as outreach, education,
and marketing materials, but also written notices
requiring a response from an individual and written
notices to an individual such as those pertaining to
rights or benefits.
iv. The nondiscrimination notice shall also be posted in at
least a 12-point font in conspicuous physical locations
where the Contractor interacts with the public, and on
the Contractor's website in a location that allows any
visitor to the website to easily locate the information.
V. The nondiscrimination notice shall include all legally
required elements under the applicable subsections of
County of Fresno
22-20101 Al
Page 5 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
Gov. Code section 11135.
vi. The nondiscrimination notice shall include information
on how to file a discrimination grievance directly with
the DHCS Office of Civil Riqhts, in addition to
information about how to file a discrimination grievance
with the County and the U.S. Health and Human
Services Office for Civil Rights.
vii. The Contractor is not prohibited from posting the
nondiscrimination notice in additional publications and
communications.
3) Language Assistance Taglines
i. The Language Assistance Taglines must be sent in
conjunction with each of the following significant
notices sent to members:
a. Notices of Adverse Benefit Determination.
b. Grievance acknowledgement letter.
c. Appeal acknowledgement letter.
d. Grievance resolution letter.
e. Notice of Appeal Resolution.
ii. The Contractor shall post Department-approved taglines
in a conspicuously visible size (no less than 12-point
font), in English and at least the top 15 non-English
languages in the State (as determined by the
Department), informing members, potential members,
and the public of the availability of no-cost language
assistance services, including assistance in non-
English languages and the provision of free auxiliary
aids and services for people with disabilities.
iii. Taglines shall be posted in any documents that are vital
or critical to obtaining services and/or benefits,
conspicuous physical locations where the Contractor
interacts with the public, on the Contractor's website in
County of Fresno
22-20101 Al
Page 6 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
a location that allows any visitor to the website to easily
locate the information, and in all member information
and other information notice, in accordance with federal
and state requirements.
4) Effective Communication with Individuals with Disabilities
i. The Contractor shall comply with all applicable
requirements of federal and state disability law and take
appropriate steps to ensure effective communication
with individuals with disabilities.
ii. The Contractor shall provide appropriate auxiliary aids
and services to persons with impaired sensory, manual,
or speaking skills, including the provision of qualified
interpreters and written materials in alternative formats,
free of charge and in a timely manner, when such aids
and services are necessary to ensure that individuals
with disabilities have an equal opportunity to participate
in, or enjoy the benefits of, the Contractor's covered
services, programs, and activities.
iii. The Contractor shall provide interpretive services and
make member information available in the following
alternative formats: Braille, audio format, large print (no
less than 20-point font), and accessible electronic
format (such as a data CD). In determining what types of
auxiliary aids and services are necessary, the
Contractor shall give "primary consideration" to the
individual's request of a particular auxiliary aid or
service.
iv. Auxiliary aids and services include:
a. Qualified interpreters on-site or through VRI
services; note takers; real-time computer-aided
transcription services; written materials;
exchange of written notes; telephone handset
amplifiers; assistive listening devices; assistive
listening systems; telephones compatible with
hearing aids; closed caption decoders; open and
closed captioning, including real-time captioning;
voice, text, and video-based telecommunication
County of Fresno
22-20101 Al
Page 7 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
products and systems, text telephones (TTYs),
videophones, captioned telephones, or equally
effective telecommunications devices; videotext
displays; accessible information and
communication technology; or other effective
methods of making aurally delivered information
available to individuals who are deaf or hard of
hearing.
b. Qualified Readers; taped texts; audio recordings;
Braille materials and displays; screen reader
software; magnification software; optical readers;
secondary auditory programs; large print
materials (no less than 20-point font); accessible
information and communication technologv; or
other effective methods of making visually
delivered materials available to individuals who
are blind or have low vision.
AThe CORtraeter shall nreyirde all wFitten materials fer potential benefiniaries
and beRefiGiariec in a font ciZe��ialler t�i poipt (42 G.C C?
B. The Gontrantor shall ensure its written materials that are nri+iGal to
obtaining serVines are available in alternative formats, i ipen request of the
potential beflefloiary er beReflo at R0 GGSt Written material that are
�tfEal tebta♦ '} g ��rnsefRGOIL�de`" at a minimum nreyider direntories
craircccrn�.r
beflefIElary hen csappeal 5'T aRGe rn 0tiGes, deniova
termination notines aR d the Gen+raGtor'c mental health e`ti Ga+ion
r
,materials. i42 G.F.R. § 438 10i�.)
C. The Gentraeter shall make its written materials that are eritinal to obtaining
seniiees and irdingo at a minimum, nreyider rtirenteries benefida ni
0 f
hanrdbeeks anneal aR d nrieVanne netiees denial and termination notines
aR d the Gentraeter's mental health materials, available in the
prevalent non ERglish languages On the GO in+y, (42 G.F.R. § 48 1n�.)
1) The GentraGtOF shall netify hen daries prespentiye hen Giories
c-wiTcraU tlyr��urrrry��J "'err �urrc�'Y�""h'�crrv�acrr �..r
anrd members of the pi iblin that written translation is ava lable in
prevalent languages free of post anrd how to onness these
materials. (42 G.F.R. § 438 10(d)/5\/i\ /iii\• \Nelf. 52. Inc+ Code §
County of Fresno
22-20101 Al
Page 8 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
'1 4727(a)(1); Gal Code Regs tot. Q § 1810.4 10, s bd /o\,n�ra.
iH
2) Prevalent non language means a language identified the
primary Iapg,,age of 3,000 beneficiaries or five percent of the
,
beneficiary population (whichever is lower) in the Gentractor's
sePAGe-aroa as iRdiGated OR nnEDs. (42 G.F.R. § 438. Gal.
Conde Rpm tit Q § 1810.410, s, bd /a\ pore (3).)
D. The Centracter shall make auxiliary aids and services available ,,pan
request an.d frra�ree of Gl afge to eaGh benefi /42 G.F.R. § 438 1n/�)
(4).) The Gentractor shall also netify beneficiaries prospective
,
belief ipi�^^o ? andmembers re f the bpiu lin t these are available
frree Gf Gharge and hew to aGGeSe� ^ SeWiGeS. /47 G.F.R. § 438 1�a/
/e.\/ii\ /iii\• Welf. Q Inst. Cede § 14727(a)(2) \
E. The CentraGter shall make oral interpretatien onrl auxiliary oirls S i�s
Teletypewriter-T-elephgRe/T-ext T-eiep h o n e /TT V/T D V\ a nd /\m eFiGa n SigT
Language ( S ) aVailahle and free of � �v rge for an lann„age. (/17
,
G.F.R. 438 )`) /n\ /.C,.,\ \ (;GRtra r s+h�,all nnetify beR� fiGia�S
prr
pespeG of r-- piries,, -;4nd mermbei.rs-of-tttn'abk that these cseFVices
are available free of charge anrd how to a•EGeSS these seWiGs. (42 G.F.R.
§ 438 1 n(v-d)/r-.\/i\ (iii)• Welf. Q Inst Code § 14727/a\(1
F. Nenv-disEriminatien Netice anv-d Taglines
1) The (`�aGtOF shall pest /1\ a D a�p nt_aapppreyed
nonv-discrimination notice aped (2) language taglines in a conspic,,eusly
visible font size in at least a 12-point font in English in the top 15 non_
Gno�lich, languages in the State, and any gg
other lanuaes, as determined
bythe Department, i l explaining the availability of free language assistance
services, d inGlu ding written translation aR oral interpretation an, rd
information on homy to request auxiliary ands and services inch ding
,
vmaaterial�aallternative formats. The n�SGrm�aateR ROtcee and tagliRes,
shall iRGlu de the tell free and TTWTDY telephone number of the
GORtraa GtOr'S mrTel' ber/GLAstte mmeserv+Ge LARTt for ebtaining theses %--s
and shall he posted as follows-
a) In conspic,,oUs physical locations where the Gentractnr
interacts with the pub"G•
,
County of Fresno
22-20101 Al
Page 9 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
h\ OR the internet website published avid maintained by +he
Gontrantor, in a manner that allows benefiniaries nresnentiye
beefiGia r�? and members of the p blin +G eaGily IGGate the
e
and
gG) in the benefiGiary handbook, all materials GritiGal toobtaining
serVines e id av informational nntines targeteld to be%finiaries
and members of the p iblin (innli vding notines of ag+inn) (42
G.F.R. § 4381flyv(d)(2\ (�etf Cede,Q Ins+ § 14727lh\
(G)(1` \
7\ The c CORtraEter's�ReRdiSGriFF1i ati0R nnotiGe anrd langi loge lines
�must he nensnini lei isly visible fen+ size no smaller than 12
nnint (42 G.F.R. S AIQ 10(d)(` ) (d)(6)(ii) \
3 The rc GeRtraEter shall provide infermotieR to all
nrp speGtiye beRafini�? and embers of the p iblis en hGW to file
a Disnrimina+ion Grleyange with:
ache Gnntranter anld the Department if there is a gongern of
�vrnTcrac �rrcr urcrrTcrrrrr T���cvrTccm-vr
ldis mina+inn based on sex, ra GGIGF, FeligiE)R, an y
rnratienoIerigiR,r-ethRin greUp dentifTGa+ion age men+oI
disability, ehvsinal disability, merdinal Genrdi+ionr genetic
inferma+inne marital status, g rdenere gender identity or sexual
e
erienta+inn (Welf. Q_ Inc+ Conde § 14777(a)(4) \
b) Thee United States DepartmeRt of Health and Human SerViGes
Offine for Givil Rights if there is a gonnern of idisnrimina+inn
based en .olnr national origiii,n sex age er disability.
(Welf. & Inst Code § 14727(a)(51 \
4. Handbook
A. The Contractor shall provide members benefiGiaries with a copy of the
handbook and provider directory when the member hem first
accesses services and thereafter upon request. (Cal. Code Regs., tit. 9, §
1810.360.)
B. The Contractor shall ensure that the handbook includes the current toll-
free telephone number(s) that provides information in threshold languages
and is available twenty-four hours a day, seven days a week. (Cal. Code
Regs., tit. 9, § 1810.405, subd. (d).)
County of Fresno
22-20101 Al
Page 10 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
C. The member "ery handbook shall include information that enables
the member "e ms to understand how to effectively use the
managed care program. This information shall include, at a minimum:
1) Benefits provided by the Contractor. (42 C.F.R. § 438.10(g)(2)(i).)
2) How and where to access any benefits provided by the Contractor,
including any cost sharing, and how transportation is provided. (42
C.F.R. § 438.10(g)(2)(ii).)
a) The amount, duration, and scope of benefits available under
the Contract in sufficient detail to ensure that members
beRefiniarioc understand the benefits to which they are
entitled. (42 C.F.R. § 438.10(g)(2)(iii).)
b) Procedures for obtaining benefits, including any
requirements for service authorizations and/or referrals for
specialty care and for other benefits not furnished by the
member's beRefiniar provider. (42 C.F.R. §
438.10(g)(2)(iv).)
c) Any restrictions on the member's benefiGiar freedom of
choice among network providers. (42 C.F.R. §
438.10(g)(2)(vi).)
d) The extent to which, and how, members beRefiGiarioc may
obtain benefits from out-of-network providers. (42 C.F.R. §
438.10(g)(2)(vii).)
e) Cost sharing, if any, consistent with the State Plan. (42
C.F.R. § 438.10(g)(2)(viii); State Plan § 4.18.)
f) Member Benefiniary rights and responsibilities, including
the elements specified in § 438.100 as specified in Section
7 of this Attachment. (42 C.F.R. § 438.10(g)(2)(ix).)
g) The process of selecting and changing the member's
beRefiGiaryi provider. (42 C.F.R. § 438.10(g)(2)(x).)
County of Fresno
22-20101 Al
Page 11 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
h) Grievance, appeal, and State Hearing procedures and
timeframes, consistent with 42 C.F.R. sections 438.400
through 438.424, in a state-developed or state-approved
description. Such information shall include:
1) The right to file grievances and appeals;
The Contractor shall include information on filing a
Discrimination Grievance with the Contractor, the
Department's Office of Civil Rights and the U.S.
Health and Human Services Office for Civil Rights,
and shall specifically include information stating that
the Contractor complies with all state and federal civil
rights laws. If a member beRefiGiary believes they
have been unlawfully discriminated against, they have
the right to file a Discrimination Grievance with the
Contractor, the Department's Office of Civil Rights,
and the United States Department of Health and
Human Services, Office for Civil Rights.
2) The requirements and timeframes for filing a
grievance or appeal;
3) The availability of assistance in the filing process;
4) The right to request a State Hearing after the
Contractor has made a determination on a member's
beRefiGiar appeal which is adverse to the member
beRefiGiary;
5) The fact that, when requested by the member
honor, benefits that the Contractor seeks to
reduce or terminate will continue if the member
benefiGiary files an appeal or a request for State
Hearing within the timeframes specified for filing, and
that the member hory may, consistent with
state policy, be required to pay the cost of services
furnished while the appeal or State Hearing is
pending if the final decision is adverse to the member
beRefiGiary. (42 C.F.R. § 438.10(g)(2)(xi).)
County of Fresno
22-20101 Al
Page 12 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
i) How to exercise an advance directive, as set forth in 42
C.F.R. 438.30). (42 C.F.R. § 438.10(g)(2)(xii).)
D How to access auxiliary aids and services, including
additional information in in alternative formats or languages.
(42 C.F.R. § 438.10(g)(2)(xiii).)
k) The Contractor's toll-free telephone number for member
services, medical management, and any other unit providing
services directly to members henefiniaries. (42 C.F.R. §
438.10(g)(2)(xiv).)
1) Information on how to report suspected fraud or abuse. (42
C.F.R. § 438.10(g)(2)(xv).)
m) Additional information that is available upon request,
includes the following:
1) Information on the structure and operation of the
Contractor.
2) Physician incentive plans as set forth in 42 C.F.R.
section 438.3(i). (42 C.F.R. § 438.10(f)(3).)
D. The Contractor shall give each member hem notice of any
significant change (as defined by the Department) to information in the
handbook at least 30 days before the intended effective date of the
change. (42 C.F.R. § 438.10(g)(4).)
E. Consistent with 42 Code of Federal Regulations section 438.10(g){a}and
Cal. Code Regs., tit. 9, section 1810.360, subdivision (e), the handbook
will be considered provided if the Contractor:
1) Mails a printed nenv of the information to the henefisiary's mailing
address before the henefiniary first reoeiyes a sneoialty mental
health seniine•
e
2) Mails a printed copy of the information upon the henefiniani's
request to the member's henefisiar„I mailing address;
County of Fresno
22-20101 Al
Page 13 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
3) Provides the information by email after obtaining the member's
heRefiniary-s agreement to receive the information by email;
4) Posts the information on the Contractor's website and advises the
member hem in paper or electronic form that the information
is available on the internet and includes the applicable internet
addresses, provided that members henefiGiaries with disabilities
who cannot access this information online are provided auxiliary
aids and services upon request at no cost; or,
5) Provides the information by any other method that can reasonably
be expected to result in the member hem receiving that
Information. If the GGRtra Gt0F preyildes fho hart rdbeek in perSGR
when the heneflnla Fy first reneiVes Spenialty mental health seFVines
e
the date aR d methe d of delivery shall he rdOGUrneRterd in the
heRefiniary's file
5. Provider Directory
A. The Contractor must follow the Department's provider directory policy,
which the Department implemented via Mental Health and Substance Use
Disorder Services Information Notice 18-020, and other applicable Mental
Health and Substance Use Disorder Services Information Notices that
may be issued subsequent to the effective date of this contract.
B. The Contractor shall make provider directories available in electronic and
paper form upon request, and maintain a publicly accessible
standards-based Provider Directory API as described in 42 CFR
section 431.70 and BHIN 22-068, and meet the same technical
standards of the Patient Access API and ensure that the provider
directories include the following information for all network providers,
including each licensed, waivered, or registered mental health provider
employed by the Contractor, each provider organization or individual
practitioner contracting with the Contractor, and each licensed, waivered,
or registered mental health provider employed by a provider organization
to deliver Medi-Cal services-
1) Information on the category or categories of services available from
each provider. (42 C.F.R. § 438.10(h)(1)(v).)
County of Fresno
22-20101 Al
Page 14 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
2) The names, medical group/foundation, independent
Physician/provider associations, and any group affiliations,
street addresses, telephone numbers, specialty, and website URLs
of current contracted providers by category. (42 C.F.R. §
438.10(h)(1)(i)-(v).)
3) The cultural and linguistic capabilities of network providers,
including languages (including ASL) offered by the provider or a
skilled medical interpreter at the provider's office. (42 C.F.R. §
438.10(h)(1)(vii).)
4) Whether network providers' offices/facilities have accommodations
for people with physical disabilities, including offices, exam room(s)
and equipment. (42 C.F.R. § 438.10(h)(1)(viii).)
5) A means to identify which providers are accepting new members
beRefiGiari . (42 C.F.R. § 438.10(h)(1)(vi).)
6) Type of practitioner as appropriate.
7) National Provider Identifier number.
8) California License number and type of license.
9) Whether the provider has completed cultural competence training.
10) Hours and days when each services location is open,
including the availability of evening and /or weekend hours.
C. Information included in a paper provider directory shall be updated at least
monthly and electronic provider directories shall be updated no later than
30 calendar days after the Contractor receives updated provider
information. The Contractor shall ensure processes are in place to allow
providers to promptly verify or submit changes to the information required
to be in the directory. (42 C.F.R. § 438.10(h)(3).)
D. Provider directories shall be made available on the Contractor's website in
a machine readable file and format as specified by the Secretary. (42
C.F.R. § 438.10(h)(4).)
County of Fresno
22-20101 Al
Page 15 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
6. Advance Directives
A. For purposes of this contract, advance directives means a written
instruction, such as a living will or durable power of attorney for health
care, recognized under California law, relating to the provision of health
care when the individual is incapacitated. (42 C.F.R. § 489.100.)
B. The Contractor shall maintain written policies and procedures on advance
directives, which include a description of applicable California law. (42
C.F.R. §§ and 438.3(j)(1)-(3), 422.128.) Any written materials prepared by
the Contractor for members beRefiGiar; shall be updated to reflect
changes in state laws governing advance directives as soon as possible,
but no later than 90 days after the effective date of the change. (42 C.F.R.
§ 438.3(j)(4).)
C. The Contractor shall provide adult members beRefiGiar; with the written
information on advance directives. (42 C.F.R. § 438.3(j)(3).)
D. The Contractor shall not condition the provision of care or otherwise
discriminate against an individual based on whether or not the individual
has executed an advance directive. (42 C.F.R. §§ 422.128(b)(1)(ii)(F),
438.3(j).)
E. The Contractor shall educate staff concerning its policies and procedures
on advance directives. (42 C.F.R. §§ 422.128(b)(1)(ii)(H), 438.30).)
7. Member Renefi^mar-., Rights
A. The parties to this contract shall comply with applicable laws and
regulations relating to patients' rights, including but not limited to W&I
Code section 5325, Cal. Code Regs., tit. 9, sections 862 through 868, and
42 C. F. R. section 438.100. The Contractor shall ensure that its
subcontractors comply with all applicable patients' rights laws and
regulations.
B. The Contractor shall have written policies regarding the member
"eRary rights specified in this section and ensure that its staff,
subcontractors, and providers take those rights into account when
providing services, including the right to:
County of Fresno
22-20101 Al
Page 16 of 16
Exhibit A— Attachment 11
INFORMATION REQUIREMENTS
1) Receive information in accordance with 42 C.F.R. section 438.10.
(42 C.F.R. § 438.100(b)(2)(i).)
2) Be treated with respect and with due consideration for their dignity
and privacy. (42 C.F.R. § 438.100(b)(2)(ii).)
3) Receive information on available treatment options and
alternatives, presented in a manner appropriate to the member's
benefiGiaro condition and ability to understand. (42 C.F.R. §
438.1 00(b)(2)(iii).)
4) Participate in decisions regarding their health care, including the
right to refuse treatment. (42 C.F.R. § 438.100(b)(2)(iv).)
5) Be free from any form of restraint or seclusion used as a means of
coercion, discipline, convenience, or retaliation. (42 C.F.R. §
438.100(b)(2)(v).)
6) Request and receive a copy of their medical records, and to
request that they be amended or corrected. (42 C.F.R. §
438.100(b)(2)(vi); 45 C.F.R. §§ 164.524,164.526.)
7) Be furnished services in accordance with 42 C.F.R. §§ sections
438.206 through 438.210. (42 C.F.R. § 438.100(b)(3).)
8) Freely exercise their rights without adversely affecting the way the
Contractor, subcontractor, or provider treats the member
ben aF!,�. (42 C.F.R. § 438.100(c).)
County of Fresno
22-20101 Al
Page 1 of 25
Exhibit A— Attachment 12
BENEFirinov MEMBER PROBLEM RESOLUTION
1. General Provisions
A. The Contractor shall have a grievance and appeal system in place for
members beRGfiniarioc. (42 C.F.R. §§ 438.228(a), 438.402(a); Cal. Code
Regs., tit. 9, § 1850.205.) The grievance and appeal system shall be
implemented to handle appeals of adverse benefit determinations and
grievances, and shall include processes to collect and track information
about them. The Contractor's member benefiniary problem resolution
processes shall include:
1) A grievance process;
2) An appeal process; and,
3) An expedited appeal process. (Cal. Code Regs., tit. 9, §
1850.205(b)(1)-(b)(3).)
B. For the grievance, appeal, and expedited appeal processes, the
Contractor shall comply with the following requirements:
1) The Contractor shall ensure that each member benefiniary has
adequate information about the Contractor's problem resolution
processes by taking at least the following actions:
a) Including information describing the grievance, appeal, and
expedited appeal processes in the Contractor's member
beR fly booklet and providing the member benefi^iary
handbook to members benefiniarioc as described in
Attachment 11 of this contract. (Cal. Code Regs., tit. 9, §
1850.205(c)(1)(A).)
b) Posting notices explaining grievance, appeal, and expedited
appeal process procedures in locations at all Contractor
provider sites. Notices shall be sufficient to ensure that the
information is readily available to both members
beRefiniaFioc and provider staff. The posted notice shall also
explain the availability of State Hearings after the exhaustion
of an appeal or expedited appeal process, including
information that a State Hearing may be requested whether
or not the member "eat has received a notice of
County of Fresno
22-20101 Al
Page 2 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
adverse benefit determination. For the purposes of this
Section, a Contractor provider site means any office or
facility owned or operated by the Contractor or a provider
contracting with the Contractor at which members
beRefiniaFioc may obtain specialty mental health services.
(Cal. Code Regs., tit. 9, §§ 1850.205(c)(1)(B) and 1850.210.)
c) Make available forms that may be used to file grievances,
appeals, and expedited appeals and self-addressed
envelopes that members beRefi^iari can access at all
Contractor provider sites without having to make a verbal or
written request to anyone. (Cal. Code Regs., tit. 9, §
1850.205(c)(1)(C).)
d) Give beneficiaries any reasonable assistance in completing
the forms and other procedural steps related to a grievance
or appeal. This includes, but is not limited to, providing
interpreter services and toll-free numbers with TTY/TDD and
interpreter capability. (42 C.F.R. § 438.406(a); 42 C.F.R. §
438.228(a).)
2) The Contractor shall allow members beRefiGiari to file grievances
and request appeals. (42 C.F.R. § 438.402(c)(1).) The Contractor
shall have only one level of appeal for members beRefiGiari (42
C.F.R. § 438.402(b); 42 C.F.R. § 438.228(a).)
3) A member beRefiGiary may request a State Hearing after receiving
notice under 438.408 that the adverse benefit determination is
upheld. (42 C.F.R. § 438.402(c)(1); 42 C.F.R. § 438.408(f).)
4) The Contractor shall adhere to the notice and timing requirements
in §438.408. If the Contractor fails to adhere to these notice and
timing requirements, the member benefiGiar is deemed to have
exhausted the Contractor's appeals process and may initiate a
State Hearing. (42 C.F.R. §§ 438.402(c)(1)(i)(A), 438.408(c)(3).)
County of Fresno
22-20101 Al
Page 3 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
5) The Contractor shall acknowledge receipt of each grievance,
appeal, and request for expedited appeal of adverse benefit
determinations to the member how in writing. (42 C.F.R. §
438.406(b)(1); 42 C.F.R. § 438.228(a); Cal. Code Regs., tit. 9, §
1850.205(d)(4).) Grievances received over the telephone or in-
person by the Contractor, or a network provider of the Contractor,
that are resolved to the member's benefiniar satisfaction by the
close of the next business day following receipt are exempt from
the requirement to send a written acknowledgment.
6) The Contractor shall allow a provider, or authorized representative,
acting on behalf of the member "er and with the member's
beRefiGiary-'&written consent to request an appeal, file a grievance,
or request a State Hearing. (42 C.F.R. § 438.402(c)(1)(i)-(ii); Cal.
Code Regs., tit. 9, § 1850.205(c)(2).)
7) The Contractor shall allow a member's beRefiniaryL authorized
representative to use the grievance, appeal, or expedited appeal
processes on the member's beReftiar behalf. (Cal. Code Regs.,
tit. 9, § 1850.205(c)(2).)
8) At the member's beRefiniaryis request, the Contractor shall identify
staff or another individual, such as a legal guardian, to be
responsible for assisting a member "ery with these
processes, including providing assistance in writing the grievance,
appeal, or expedited appeal. If the individual identified by the
Contractor is the person providing specialty mental health services
to the member "ery requesting assistance, the Contractor
shall identify another individual to assist that member beryl
(Cal. Code Regs., tit. 9, § 1850.205(c)(4).) Assistance includes, but
is not limited to, auxiliary aids and services upon request, such as
providing interpreter services and toll-free numbers with TTY/TDD
and interpreter capability. (42 C.F.R. § 438.406(a).)
9) The Contractor shall not subject a member hor ;� to
discrimination or any other penalty for filing a grievance, appeal, or
expedited appeal. (Cal. Code Regs., tit. 9, § 1850.205(c)(5).)
10) The Contractor's procedures for the member "ery problem
resolution processes shall maintain the confidentiality of each
County of Fresno
22-20101 Al
Page 4 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
member's beRefi^iaFY-6 information. (Cal. Code Regs., tit. 9, §
1850.205(c)(6).)
11) The Contractor shall include a procedure to transmit issues
identified as a result of the grievance, appeal or expedited appeal
processes to the Contractor's Quality Improvement Committee, the
Contractor's administration or another appropriate body within the
Contractor's operations. The Contractor shall consider these issues
in the Contractor's Quality Improvement Program, as required by
Cal. Code Regs., tit. 9, §1810.440(a)(5). (Cal. Code Regs., tit. 9, §
1850.205(c)(7).)
12) The Contractor shall ensure that decision makers on grievances
and appeals of adverse benefit determinations were not involved in
any previous level of review or decision-making, and were not
subordinates of any individual who was involved in a previous level
of review or decision-making. (42 C.F.R. § 438.406(b)(2)(i); 42
C.F.R. § 438.228(a).)
13) The Contractor shall ensure that individuals making decisions on
the grievances and appeals of adverse benefit determinations,
have the appropriate clinical expertise, as determined by the
Department , in treating the member's benefiGiary!& condition or
disease, if the decision involves an appeal based on a denial of
medical necessity, a grievance regarding denial of a request for an
expedited appeal, or if the grievance or appeal involves clinical
issues.(42 C.F.R. § 438.406(b)(2)(ii)(A)-(C); 42 C.F.R. §
438.228(a).)
14) The Contractor shall provide the member hory a reasonable
opportunity, in person and in writing, to present evidence and
testimony and make legal and factual arguments. The Contractor
must inform the member benefi^iary of the limited time available for
this sufficiently in advance of the resolution timeframe for appeals
specified in section 438.408(b) and (c) in the case of expedited
resolution. (42 C.F.R. § 438.406(b)(4).)
County of Fresno
22-20101 Al
Page 5 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
15) The Contractor shall ensure that decision makers on grievances
and appeals of adverse benefit determinations take into account all
comments, documents, records, and other information submitted by
the member beRefiGiaFy or member's be%fi^iaryi representative,
without regard to whether such information was submitted or
considered in the initial adverse benefit determination. (42 C.F.R. §
438.406(b)(2)(iii); 42 C.F.R. § 438.228(a).)
16) The Contractor shall provide the member benefiGiary and their
representative the member's beRefiGiaryis. case file, including
medical records, other documents and records, and any new or
additional evidence considered, relied upon, or generated by the
Contractor in connection with the appeal of the adverse benefit
determination. (42 C.F.R. § 438.406(b)(5).)
17) The Contractor shall provide the member "ems and their
representative the member's beRefiGiaryi case file free of charge
and sufficiently in advance of the resolution timeframe for standard
and expedited appeal resolutions, (42 C.F.R. § 438.408(b)-(c).) For
standard resolution of an appeal and notice to the affected parties,
the Contractor must comply with the Department established
timeframe of 30 calendar days from the day the Contractor receives
the appeal. For expedited resolution of an appeal and notice to
affected parties, the Contractor must comply with the Department
established timeframe of 72 hours after the Contractor receives the
appeal. (42 C.F.R. § 438.406(b)(5).)
18) The Contractor shall treat oral inquiries seeking to appeal an
adverse benefit determination as appeals (to establish the earliest
possible filing date for the appeal) and must confirm these oral
inquiries in writing, unless the member "ery or the provider
requests expedited resolution. (42 C.F.R. § 438.406(b)(3).)
19) The Contractor's member benefiGiary problem resolution process
shall not replace or conflict with the duties of county patient's rights
advocates. (W&I Code § 5520.)
County of Fresno
22-20101 Al
Page 6 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
2. Handling of Grievances and Appeals
The Contractor shall adhere to the following record keeping, monitoring, and
review requirements:
A. Maintain a grievance and appeal log and record grievances, appeals, and
expedited appeals in the log within one working day of the date of receipt
of the grievance, appeal, or expedited appeal. (42 C.F.R. § 438.416(a);
Cal. Code Regs., tit. 9, § 1850.205(d)(1).) Each record shall include, but
not be limited to: a general description of the reason for the appeal or
grievance the date received, the date of each review or review meeting,
resolution information for each level of the appeal or grievance, if
applicable, and the date of resolution at each level, if applicable, and the
name of the covered person whom the appeal or grievance was filed. (42
C.F.R. § 438.416(b)(1)-(6).)
B. Record in the grievance and appeal log or another central location
determined by the Contractor, the final dispositions of grievances,
appeals, and expedited appeals, including the date the decision is sent to
the member "eFy. If there has not been final disposition of the
grievance, appeal, or expedited appeal, the reason(s) shall be included in
the log. (Cal. Code Regs., tit. 9, § 1850.205(d)(2).)
C. Provide a staff person or other individual with responsibility to provide
information requested by the member "er�4 or the member's
benefinia� representative regarding the status of the member's
benefin4rYi grievance, appeal, or expedited appeal. (Cal. Code Regs., tit.
9, § 1850.205(d)(3).)
D. Identify in its grievance, appeal, and expedited appeal documentation, the
roles and responsibilities of the Contractor, the provider, and the member
"e''' ;Y. (Cal. Code Regs., tit. 9, § 1850.205(d)(5).)
E. Provide notice, in writing, to any provider identified by the member
"eR ;y' or involved in the grievance, appeal, or expedited appeal of the
final disposition of the member's beRefiniary-� grievance, appeal, or
expedited appeal. (Cal. Code Regs., tit. 9, § 1850.205(d)(6).)
County of Fresno
22-20101 Al
Page 7 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
F. Maintain records in the grievance and appeal log accurately and in a
manner accessible to the Department and available upon request to CMS.
(42 C.F.R. § 438.416(c).)
3. Grievance Process
The Contractor's grievance process shall, at a minimum:
A. Allow members benefi^iarioo to file a grievance either orally, or in writing
at any time with the Contractor; (42 C.F.R. § 438.402(c)(2)(i) and (c)(3)(i).)
B. The Contractor shall provide to the member beRefiGiary written
acknowledgement of receipt of the grievance. The acknowledgment letter
shall include the date of receipt, as well as the name, telephone number,
and address of the Plan representative who the member benefiGiary may
contact about the grievance. The written acknowledgement to the
member "ems must be postmarked within five calendar days of
receipt of the grievance. Grievances received over the telephone or in-
person by the Contractor, or a network provider of the Contractor, that are
resolved to the member's beR8fiGiaFY-6 satisfaction by the close of the
next business day following receipt are exempt from the requirement to
send a written notification of resolution using the Written Notification of
Grievance Resolution form.
C. Resolve each grievance as expeditiously as the member's benefiGiar
health condition requires not to exceed 90 calendar days from the day the
Contractor receives the grievance. (42 C.F.R. § 438.408(a)-(b)(1).) The
Contractor may extend the timeframe for processing a grievance by up to
14 calendar days if the member beRefiGiary requests an extension, or if
the Contractor determines, to the satisfaction of DHCS upon request, that
there is a need for additional information and that the delay is in the
member's beRefiGiary-c interest. (42 C.F.R. § 438.408(c)(1)(i)-(ii).) If the
Contractor extends the timeframe, the Contractor shall, for any extension
not requested by the member beRefiGiary, make reasonable efforts to give
the member "ears prompt oral notice of the delay and give the
member beRefiGiary written notice of the extension and the reasons for
the extension within 2 calendar days of the decision to extend the
timeframe. The Contractor's written notice of extension shall inform the
member hory of the right to file a grievance if they disagree with the
Contractor's decision (42 C.F.R. § 438.408(c)(2)(i)-(ii).) The written notice
County of Fresno
22-20101 Al
Page 8 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
of the extension is not a Notice of Adverse Benefit Determination. (Cal.
Code Regs., tit. 9, § 1810.230.5.)
D. The timeframe for resolving grievances related to disputes of a
Contractor's decision to extend the timeframe for making an authorization
decision shall not exceed 30 calendar days.
E. Provide written notification to the member "ery or the appropriate
representative of the resolution of a grievance and documentation of the
notification or efforts to notify the member beRefiGiary, if they could not be
contacted. (Cal. Code Regs., tit. 9, § 1850.206(c).)
F. Notify the member beRefiGiar of the resolution of a grievance in a format
and language that meets applicable notification standards. (42 C.F.R. §
438.408(d)(1); 42 C.F.R. § 438.10.)
4. Discrimination Grievances
A. For Discrimination Grievances:
1) The Contractor shall designate a Discrimination Grievance
Coordinator who is responsible for ensuring compliance with
federal and state nondiscrimination requirements, and investigating
Discrimination Grievances related to any action that would be
prohibited by, or out of compliance with, federal or state
nondiscrimination law. (W&I Code § 14727(a)(4); 45 C.F.R. § 84.7;
34 C.F.R. § 106.8; 28 C.F.R. § 35.107; see 42 U.S.C. § 18116(a);
California's Medicaid State Plan, Section 7, Attachments 7.2-A and
7.2-B.)
2) The Contractor shall adopt procedures to ensure the prompt and
equitable resolution of discrimination-related complaints. (W&I
Code § 14727(a)(4); 45 C.F.R. § 84.7; 34 C.F.R. § 106.8; 28 C.F.R.
§ 35.107-1 see 42 U.S.C. § 18116(a); California's Medicaid State
Plan, Section 7, Attachments 7.2-A and 7.2-B.) The Contractor
shall not require a member benefi^iary to file a Discrimination
Grievance with the Contractor before filing the complaint directly
with the DHCS Office of Civil Rights and the U.S. Health and
Human Services Office for Civil Rights.
County of Fresno
22-20101 Al
Page 9 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
3) Within ten calendar days of mailing a Discrimination Grievance
resolution letter to a member hory, the Contractor must
submit the following information regarding the complaint to the
DHCS Office of Civil Rights (see California Medicaid State Plan, §
7, Attachments 7.2-A and 7.2-13):
a) The original complaint.
b) The provider's or other accused party's response to the
complaint.
c) Contact information for the personnel primarily responsible
for investigating and responding to the complaint on behalf
of the Contractor.
d) Contact information for the member ben�cneficiary filing the
complaint, and for the provider or other accused party that is
the subject of the complaint.
e) All correspondence with the member how regarding
the complaint, including, but not limited to, the Discrimination
Grievance acknowledgment letter and resolution letter sent
to the member benefiGiaFy.
f) The results of the Contractor's investigation, copies of any
corrective action taken, and any other information that is
relevant to the allegation(s) of discrimination.
5. Appeals Process
A. The Contractor's appeal process shall, at a minimum:
1) Allow a member benefiGiaFY, or a provider or authorized
representative acting on the member's beRefi^iaryis behalf, to file
an appeal orally or in writing. (42 C.F.R. § 438.402(c)(3)(ii).) The
member benefiGiary may file an appeal within 60 calendar days
from the date on the adverse benefit determination notice (42
C.F.R. § 438.402(c)(2)(ii).);
County of Fresno
22-20101 Al
Page 10 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
2) Require a member beRefi^iaFy who makes an oral appeal that is
not an expedited appeal, to subsequently submit a written, signed
appeal. (42 C.F.R. § 438.402(c)(3)(ii).) The Contractor shall ensure
that oral inquiries seeking to appeal an adverse benefit
determination are treated as appeals, and confirmed in writing
unless the member "ems or the provider requests expedited
resolution. The date the Contractor receives the oral appeal shall
be considered the filing date for the purpose of applying the appeal
timeframes (42 C.F.R. § 438.406(b)(3).);
3) Resolve each appeal and provide notice, as expeditiously as the
member's beRefiGiary-Ls health condition requires, within 30
calendar days from the day the Contractor receives the appeal. (42
C.F.R. § 438.408(a); 42 C.F.R. § 438.408(b)(2).) The Contractor
may extend the timeframe for processing an appeal by up to 14
calendar days, if the member be aF!,, requests an extension or
the Contractor demonstrates, to the satisfaction of DHCS upon
request, that there is a need for additional information and that the
delay is in the member's beRefi^iary! interest. (42 C.F.R.
438.408(c)(1); 42 C.F.R. 438.408(b)(2).) If the Contractor extends
the timeframes, the Contractor shall, for any extension not
requested by the member benefiGiary, make reasonable efforts to
give the member benefiGiary prompt oral notice of the delay and
notify the member benefiGiary of the extension and the reasons for
the extension in writing within 2 calendar days of the decision to
extend the timeframe. The Contractor's written notice of extension
shall inform the member benefiGiary of the right to file a grievance if
they disagree with the Contractor's decision. The Contractor shall
resolve the appeal as expeditiously as the member's beRefiGiar„'s
health condition requires and no later than the date the extension
expires (42 C.F.R. § 438.408(c)(2)(i)-(iii).) The written notice of the
extension is not a Notice of Adverse Benefit Determination. (Cal.
Code Regs., tit. 9, §1810.230.5.);
County of Fresno
22-20101 Al
Page 11 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
4) Allow the member beRefiGiaFy to have a reasonable opportunity to
present evidence and testimony and make arguments of fact or
law, in person and in writing (42 C.F.R. § 438.406(b)(4).);
5) Provide the member "ery and their representative the
member's beRefiGiary-�s. case file, including medical records, and
any other documents and records, and any new or additional
evidence considered, relied upon, or generated by the Contractor in
connection with the appeal of the adverse benefit determination ,
provided that there is no disclosure of the protected health
information of any individual other than the member how (42
C.F.R. § 438.406(b)(5).); and
6) Provide the member "ems and their representative the
member's beRefiGiar"'s case file free of charge and sufficiently in
advance of the resolution timeframe for standard appeal
resolutions. For standard resolution of an appeal and notice to the
affected parties, the Contractor must comply with the Department
established timeframe of 30 calendar days from the day the
Contractor receives the appeal. For expedited resolution of an
appeal and notice to affected parties, the Contractor must comply
with the Department established timeframe of 72 hours after the
Contractor receives the appeal. (42 C.F.R. § 438.406(b)(5).)
7) Allow the member beRefiGiar" their representative, or the legal
representative of a deceased member's benefiGiar„is estate, to be
included as parties to the appeal. (42 C.F.R. 438.406(b)(6).)
B. The Contractor shall notify the member "ery, and/or their
representative, of the resolution of the appeal in writing in a format and
language that, at a minimum, meets applicable notification standards. (42
C.F.R. § 438.408(d)(2)(i); 42 C.F.R. § 438.408(e); 42 C.F.R. § 438.10.)
The notice shall contain the following:
1) The results of the appeal resolution process (42 C.F.R. §
438.408(e)(1).);
2) The date that the appeal decision was made (42 C.F.R. §
438.408(e)(1).);
County of Fresno
22-20101 Al
Page 12 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
3) If the appeal is not resolved wholly in favor of the member
heR,�aF!,A, the notice shall also contain:
a) Information regarding the member's beRefiGiar"'s right to a
State Hearing and the procedure for requesting a State
Hearing, if the member be%fiGiary has not already
requested a State Hearing on the issue involved in the
appeal; (42 C.F.R. § 438.408(e)(2)(i).) and
b) Information on the member's beRefiGiaFyis, right to continue
to receive benefits while the State Hearing is pending and
how to request the continuation of benefits; (42 C.F.R. §
438.408(e)(2)(ii).)
c) Inform the member "ems that they may be liable for
the cost of any continued benefits if the Contractor's adverse
benefit determination is upheld in the hearing. (42 C.F.R. §
438.408(e)(2)(iii).)
6. Expedited Appeal Process
A. "Expedited Appeal" is an appeal used when the mental health plan
determines (for a request from the member "ery) or the provider
indicates (in making the request on the member's beRefiGiaryis, behalf or
supporting the member's beReftiary-Ls. request) that taking the time for a
standard resolution could seriously jeopardize the member's benefiGiar
life, physical or mental health, or ability to attain, maintain, or regain
maximum function. (42 C.F.R. 438.410.)
B. The Contractor's expedited appeal process shall, at a minimum:
1) Be used when the Contractor determines or the member
beRefiGiary and/or the member's beRefi^iaryls provider certifies that
taking the time for a standard appeal resolution could seriously
jeopardize the member's beRefiGiary life, physical or mental
health or ability to attain, maintain, or regain maximum function. (42
C.F.R. § 438.410(a).)
County of Fresno
22-20101 Al
Page 13 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
2) Allow the member beRefi^iaFy to file the request for an expedited
appeal orally without requiring the member "ems to submit a
subsequent written, signed appeal. (42 C.F.R. § 438.402(c)(3)(ii).)
3) Ensure that punitive action is not taken against a provider who
requests an expedited resolution or supports a member's
benefiGiary-' expedited appeal. (42 C.F.R. § 438.410(b).)
4) Inform members beRefi^iaFi of the limited time available to
present evidence and testimony, in person and in writing, and make
legal and factual arguments for an expedited appeal. The
Contractor must inform members benefiGiari of this sufficiently in
advance of the resolution timeframe for the expedited appeal. (42
C.F.R. § 438.406(b)(4); 42 C.F.R. § 438.408(b)-(c).)
5) Resolve an expedited appeal and notify the affected parties in
writing, as expeditiously as the member's beRefi^iaryls health
condition requires and no later than 72 hours after the Contractor
receives the appeal. (42 C.F.R. § 438.408(b)(3).) The Contractor
may extend this timeframe by up to 14 calendar days if the
member "ems requests an extension, or the Contractor
demonstrates, to the satisfaction of DHCS upon request, that there
is need for additional information and that the delay is in the
member's beRefiriar interest. (42 C.F.R. § 438.408(c)(1)(i)-(ii).)
If the Contractor extends the timeline for processing an expedited
appeal not at the request of the member benefiGiary, the
Contractor shall make reasonable efforts to give the member
hor,�iaQ,� prompt oral notice of the delay, and notify the member
beRef!GiaQY of the extension and the reasons for the extension, in
writing, within 2 calendar days of the determination to extend the
timeline. The Contractor shall resolve the appeal as expeditiously
as the member's beRefiGiar health condition requires and no
later than the date the extension expires. (42 C.F.R. §
438.408(c)(2)(i) - (iii); 42 C.F.R. § 438.408(b)(3).) The written notice
of the extension is not a Notice of Adverse Benefit Determination.
(Cal. Code Regs., tit. 9, § 1810.230.5.)
County of Fresno
22-20101 Al
Page 14 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
6) Provide a member "8Fy with a written notice of the expedited
appeal disposition and make reasonable efforts to provide oral
notice to the member beRefiniary and/or their representative. The
written notice shall meet the requirements of Section 1850.207(h)
of Title 9 of the California Code of Regulations. (42 C.F.R. §
438.408(d)(2); Cal. Code Regs., tit. 9, § 1850.207(h).)
7) If the Contractor denies a request for an expedited appeal
resolution, the Contractor shall:
a) Transfer the expedited appeal request to the timeframe for
standard resolution of no longer than 30 calendar days from
the day the Contractor receives the appeal. (42 C.F.R. §
438.410(c)(1).)
b) Make reasonable efforts to give the member beRefiGiary and
their representative prompt oral notice of the denial of the
request for an expedited appeal. Provide written notice of the
decision and reason for the decision within two calendar
days of the date of the denial, and inform the member
beRefiGiaFy of the right to file a grievance if they disagree
with the decision. (42 C.F.R. § 438.410(c)(2); 42 C.F.R. §
438.408(c)(2).) The written notice of the denial of the request
for an expedited appeal is not a Notice of Adverse Benefit
Determination. (Cal. Code Regs., tit. 9, § 1810.230.5.)
7. Contractor obligations related to State Hearing
"State Hearing" means the hearing provided by the State to members
beRefiniaFioc pursuant to sections 50951 and 50953 of Title 22 of the California
Code of Regulations and section 1810.216.6 of Title 9 of the California Code of
Regulations 1810.216.6:
A. If a member "ems requests a State Hearing, the Department shall
grant the request. (42 C.F.R. § 431 .220(a)(5).) The right to a State
Hearing, how to obtain a hearing, and representation rules at a hearing
must be explained to the member beRefiniary and provider by the
Contractor in its notice of decision or Notice of Adverse Benefit
Determination. (42 C.F.R. § 431.206(b); 42 C.F.R. § 431.228(b).)
County of Fresno
22-20101 Al
Page 15 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
Members BeRefiGiarioo and providers shall also be informed of the
following:
1) A member beRefiGiaFy may request a State Hearing only after
receiving notice that the Contractor is upholding the adverse benefit
determination. (42 C.F.R. § 438.408(f)(1).)
2) If the Contractor fails to adhere to notice and timing requirements
under section 438.408, the member "ery is deemed to have
exhausted the Contractor's appeals process, and the member
"e^ ry may initiate a State Hearing. (42 C.F.R §
438.408(f)(1)(i); 42 C.F.R. § 438.402(c)(1)(i)(A).)
3) The provider may request a State Hearing only if the Department
permits the provider to act as the member's beRefiGiary!
authorized representative. (42 C.F.R. § 438.402(c)(1)(ii).)
8. Expedited Hearing
"Expedited Hearing" means a hearing provided by the State, used when the
Contractor determines, or the member beRefiGiar or the member's beRefiGiaryL
provider certifies that following the 90 day timeframe for a State Hearing as
established in 42 C.F.R. section 431.244(f)(1) would seriously jeopardize the
member's beRefiGiar"'s life, health, or ability to attain, maintain, or regain
maximum function. (42 C.F.R. § 431.244(f)(1); 42 C.F.R. § 438.410(a); Cal. Code
Regs., tit. 9, § 1810.216.4.)
9. Continuation of Services
A. A member beRefiGiary receiving specialty mental health services shall
have a right to file for continuation of specialty mental health services
pending the outcome of a State Hearing. (Cal. Code Regs., tit. 22., §
51014.2; Cal. Code Regs., tit. 9, § 1850.215.)
B. The Contractor shall continue the member's beRefiGiary's benefits while
an appeal is in process if all of the following occur:
1) The member "ery files the request for an appeal within 60
calendar days following the date on the adverse benefit
determination notice; (42 C.F.R. § 438.420(b)(1).)
County of Fresno
22-20101 Al
Page 16 of 25
Exhibit A— Attachment 12
BENEFICI v MEMBER PROBLEM RESOLUTION
2) The appeal involves the termination, suspension, or reduction of a
previously authorized service; (42 C.F.R. § 438.420(b)(2).)
3) The member's beRefi^iaFY-S services were ordered by an
authorized provider; (42 C.F.R. § 438.420(b)(3).)
4) The period covered by the original authorization has not expired;
and, (42 C.F.R. § 438.420(b)(4).)
5) The request for continuation of benefits is filed on or before the
later of the following: (42 C.F.R. § 438.420 (b)(5).)
a. Within 10 calendar days of the Contractor sending the notice
of adverse benefit determination; (42 C.F.R. § 438.420(a).);
or
b. The intended effective date of the adverse benefit
determination. (42 C.F.R. § 438.420(a).)
C. If, at the member's beRefiGiar.,'s request, the Contractor continues the
member's beRefi^ia^y's benefits while the appeal or State Hearing is
pending, the benefits must be continued until the member "ems
withdraws the appeal or request for State Hearing, the member
"eRry does not request a State Hearing and continuation of benefits
within 10 calendar days from the date the Contractor sends the notice of
an adverse appeal resolution, or a State Hearing decision adverse to the
member "ery is issued. (42 C.F.R. § 438.420(c)(1)-(3); 42 C.F.R. §
438.408(d)(2).)
D. The Contractor shall not n4ay recover the cost of continued services
furnished to the member beRefiGiary while the appeal or State Hearing
was pending if the final resolution of the appeal or State Hearing upholds
the Contractor's adverse benefit determination. (42 C.F.R. § 438.420(d);
42 C.F.R. § 431 .230(b).)
E. Contractor must automatically continue providing the disputed
services to the member while the appeal and State Hearing are
pending if all of the following conditions are met:
County of Fresno
22-20101 Al
Page 17 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
1) The member filed their appeal within the required timeframes set
forth in 42 CFR section 438.420;
2) The appeal involves the termination, suspension, or reduction of
previously authorized Covered Services;
3) The disputed services were ordered by the member's provider;
and
4) The period covered by the original authorization has not expired.
F. If Contractor, at the member's request, continues or reinstates the
provision of disputed services while an appeal or State Hearing is
pending, those services must continue until:
1) The member withdraws their request for an appeal or a State
Hearing;
2) The member fails to request a State Hearing and continuation of
disputed services within ten calendar days of when the NOA was
sent; or
3) The final State Hearing decision is adverse to the member.
G. Contractor must pay for disputed services if the member received
the disputed services while the appeal or State Hearing was pending.
Contractor must ensure the member is not billed for the continued
services even if the State Hearing finds the disputed services were
not medically necessary.
H. The Contractor shall authorize or provide the disputed services promptly,
and as expeditiously as the member's benefiGiar health condition
requires, but no later than 72 hours from the date the Contractor receives
notice reversing the determination if the services were not furnished while
the appeal was pending and if the Contractor or State Hearing officer
reverses a decision to deny, limit, or delay services. (42 C.F.R. §
438.424(a).)
I. If the decision of an appeal reverses a decision to deny the authorization
of services, and the member beRefiGiary received the disputed services
while the appeal was pending, the Contractor shall cover the cost of such
services. (42 C.F.R. § 438.424(b).)
County of Fresno
22-20101 Al
Page 18 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
J. The Contractor shall notify the requesting provider and give the member
"eRaFY written notice of any decision to deny a service authorization
request, or to authorize a service in an amount, duration, or scope that is
less than requested. (42 C.F.R. § 438.210(c); 42 C.F.R. § 438.404.)
10. Provision of Notice of Adverse Benefit Determination
A. The Contractor shall provide a member "ery with a Notice of
Adverse Benefit Determination (NOABD) under the following
circumstances:
1) The denial or limited authorization of a requested service, including
determinations based on the type or level of service, requirements
for medical necessity, appropriateness, setting, or effectiveness of
a covered benefit. (42 C.F.R. § 438.400(b)(1).)
2) The reduction, suspension, or termination of a previously
authorized service. (42 C.F.R. § 438.400(b)(2).)
3) The denial, in whole or in part, of payment for a service. (42 C.F.R.
§ 438.400(b)(3).)
4) The failure to provide services in a timely manner, as defined by the
Department. (42 C.F.R. § 438.400(b)(4).)
5) The failure of the Contractor to act within the timeframes provided
in §438.408(b)(1) and (2) regarding the standard resolution of
grievances and appeals. (42 C.F.R. § 438.400(b)(5).)
6) The denial of a member's beRefiGiary-' request to dispute a
financial liability, including cost sharing, copayments, premiums,
deductibles, coinsurance, and other member beRefiGiary financial
liabilities. (42 C.F.R. § 438.400(b)(7).)
County of Fresno
22-20101 Al
Page 19 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
B. The Contractor shall give members beR8fiGiarioc timely and adequate
notice of an adverse benefit determination in writing and shall meet the
language and format requirements of 42 Code of Federal Regulations
section 438.10. (42 C.F.R. § 438.404(a); 42 C.F.R. § 438.10.) The
NOABD shall contain the items specified in 42 Code of Federal
Regulations part 438.404 (b) and Cal. Code Regs., tit. 9, section
1850.212.
C. When the denial or modification involves a request from a provider for
continued Contractor payment authorization of a specialty mental health
service or when the Contractor reduces or terminates a previously
approved Contractor payment authorization, notice shall be provided in
accordance with Cal. Code Regs., tit. 22, section 51014.1. (Cal. Code
Regs., tit. 9, § 1850.210(a)(1).)
D. A NOABD is not required when a denial is a non-binding verbal
description to a provider of the specialty mental health services that may
be approved by the Contractor. (Cal. Code Regs., tit. 9, § 1850.210(a)(2).)
E. Except as provided in subsection F below, a NOABD is not required when
the denial or modification is a denial or modification of a request for the
Contractor payment authorization for a specialty mental health service that
has already been provided to the member "er�4. (Cal. Code Regs.,
tit. 9, § 1850.210(a)(4).)
F. A NOABD is required when the Contractor denies or modifies a payment
authorization request from a provider for a specialty mental health service
that has already been provided to the member "ery when the
denial or modification is a result of post-service, prepayment determination
by the Contractor that the service was not medically necessary or
otherwise was not a service covered by the Contractor. (Cal. Code Regs.,
tit. 9, § 1850.210(b).)
G. The Contractor shall deny the Contractor payment authorization request
and provide the member beRefiGiary with a NOABD when the Contractor
does not have sufficient information to approve or modify, or deny on the
merits, a Contractor payment authorization request from a provider within
the timeframes required by Cal. Code Regs., tit. 9, sections 1820.220 or
1830.215. (Cal. Code Regs., tit. 9, § 1850.210(c).)
County of Fresno
22-20101 Al
Page 20 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
H. The Contractor shall provide the member how with a NOABD if the
Contractor fails to notify the affected parties of a resolution of a grievance
within 90 calendar days, of an appeal decision within 30 days, or of an
expedited appeal decision within 72 hours. If the timeframe for a
grievance, appeal or expedited appeal decision is extended pursuant to
sections 1850.206, 1850.207 or 1850.208 of Title 9 of the California Code
of Regulations and the Contractor failed to notify the affected parties of its
decision within the extension period, the Contractor shall provide the
member benefiGiary with a NOABD. (42 C.F.R. § 438.408.)
I. The Contractor shall provide a member beRefiGiary with a NOABD when
the Contractor or its providers determine that the criteria for access to
SMHS in Attachment 2, section 1 have not been met and that the member
"en�iary is not entitled to any specialty mental health services from the
Contractor. The NOABD shall, at the election of the Contractor, be hand-
delivered to the member beRefiGiary on the date of the Adverse Benefit
Determination or mailed to the member "ems in accordance with
Cal. Code Regs., tit. 9, § section 1850.210(f)(1), and shall specify the
information contained in Cal. Code Regs., tit. 9, § section 1850.212(b).
(Cal. Code Regs., tit. 9, § 1850.210(g).)
J. For the purpose of this Attachment, each reference to a Medi-Cal
managed care plan in Cal. Code Regs., tit. 22, section 51014.1, shall
mean the Contractor. (Cal. Code Regs., tit. 9, § 1850.210(h).)
K. For the purposes of this Attachment, "medical service", as used in Cal.
Code Regs., tit. 22, section 51014.1, shall mean specialty mental health
services that are subject to prior authorization by a Contractor pursuant to
Cal. Code Regs., tit. 9, sections 1820.100 and 1830.100. (Cal. Code
Regs., tit. 9, § 1850.210(i).)
L. The Contractor shall retain copies of all Notices of Adverse Benefit
Determination issued to beneficiaries under this Section in a centralized
file accessible to the Department. The Department shall engage in random
reviews (Cal. Code Regs., tit. 9, § 1850.2100).)
M. The Contractor shall allow the State to engage in reviews of the
Contractor's records pertaining to Notices of Adverse Benefit
Determination so the Department may ensure that the Contractor is
notifying members benefiGiaFi in a timely manner.
County of Fresno
22-20101 Al
Page 21 of 25
Exhibit A— Attachment 12
BENEFICI v MEMBER PROBLEM RESOLUTION
11. Contents and Timing of NOABD
A. The Contractor shall include the following information in the NOABD:
1) The adverse benefit determination the Contractor has made or
intends to make. (42 C.F.R. § 438.404(b)(1).)
2) The reason for the adverse benefit determination, including the
right of the member beRefiGiary to be provided upon request and
free of charge, reasonable access to and copies of all documents,
records, and other information relevant to the member's
beRefiGiary-° adverse benefit determination. Such information
includes criteria to access SMHS, and any processes, strategies, or
evidentiary standards used in setting coverage limits. (42 C.F.R. §
438.404(b)(2).)
3) Citations to the regulations or Contractor payment authorization
procedures supporting the adverse benefit determination. (Cal.
Code Regs., tit. 9, § 1850.212(a)(3).)
4) The member's beRefiniar right to file, and procedures for
exercising, an appeal or expedited appeal with the Contractor,
including information about exhausting the Contractor's one level of
appeal and the right to request a State Hearing after receiving
notice that the adverse benefit determination is upheld. (42 C.F.R.
§ 438.404(b)(3)-(b)(4).)
5) The circumstances under which an appeal process can be
expedited and how to request it. (42 C.F.R. § 438.404(b)(5).)
6) The member's beRefiniary-� right to have benefits continue
pending resolution of the appeal, how to request that benefits be
continued, and the niFG rnstaRGes under which the beRefiGiary may
be required to pay the GG tS of these seNic;es. (42 (' F R S:
38 nnnih that the member shall not be held liable for the
cost of the benefits if the hearing decision upholds the
Contractor's adverse benefit determination.
County of Fresno
22-20101 Al
Page 22 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
7) Information about the member's beR8fiGiar"'s right to request a
State Hearing or an expedited State Hearing, including:
a) The method by which a hearing may be obtained; (Cal. Code
Regs., tit. 9, § 1850.212(a)(5)(A).)
b) A statement that the member "ery may be either self-
represented, or represented by an authorized third party
such as legal counsel, a relative, friend, or any other person;
(Cal. Code Regs., tit. 9, § 1850.212(a)(5)(B).)
c) An explanation of the circumstances under which a specialty
mental health service will be continued if a State Hearing is
requested; (Cal. Code Regs., tit. 9, § 1850.212(a)(5)(C).)
and
d) The time limits for requesting a State Hearing or an
expedited State Hearing. (Cal. Code Regs., tit. 9, §
1850.212(a)(5)(D).)
B. The Contractor shall mail the NOABD within the following timeframes:
1) For termination, suspension, or reduction of previously authorized
Medi-Cal covered services, at least 10 days before the date of
action. (42 C.F.R. § 438.404(c)(1); 42 C.F.R. § 431.211 .) The
Contractor shall mail the NOABD in as few as 5 days prior to the
date of action if the Contractor has facts indicating that action
should be taken because of probable fraud by the member
beRefiGiary, and the facts have been verified, if possible, through
secondary sources. (42 C.F.R. § 438.404(c)(1); 42 C.F.R.
§.431 .214.)
2) For denial of payment, at the time of any action affecting the claim.
(42 C.F.R. § 438.404(c)(2).)
3) For standard service authorizations that deny or limit services, as
expeditiously as the member's beRefi^iaryl condition requires not
to exceed 14 calendar days following the receipt for request for
services. (42 C.F.R. § 438.404(c)(3); 42 C.F.R. 438.210(d)(1).)
County of Fresno
22-20101 Al
Page 23 of 25
Exhibit A— Attachment 12
BENEFirinov MEMBER PROBLEM RESOLUTION
4) The Contractor may extend the 14 calendar day NOABD
determination timeframe for standard service authorization
decisions that deny or limit services up to 14 additional calendar
days if the member how or the provider requests the
extension. (42 C.F.R. § 438.404(c)(4); 42 C.F.R. §
438.210(d)(1)(i).)
5) The Contractor may extend the 14 calendar day notice of adverse
benefit determination timeframe for standard service authorization
decisions that deny or limit services up to 14 additional calendar
days if the Contractor justifies a need to the Department, upon
request, for additional information and shows how the extension is
in the member's beRefiGiaryis. best interest. (42 C.F.R. §
438.404(c)(4); 42 C.F.R. § 438.210(d)(1)(ii).)
6) If the Contractor extends the 14 calendar day notice of adverse
benefit determination timeframe for standard service authorization
decisions that deny or limit services, the Contractor shall do the
following:
a) Give the member be a;y written notice of the reason for
the extension and inform the member "ems of the right
to file a grievance if he/she disagrees with the decision; (42
C.F.R. § 438.404(c)(4)(i); 42 C.F.R. § 438.210(d)(1)(ii).) and,
b) Issue and carry out its determination as expeditiously as the
member's beRefiGiap-Is health condition requires and no
later than the date of the extension. (42 C.F.R. §
438.404(c)(4)(ii); 42 C.F.R. § 438.210(d)(1)(ii).)
7) The Contractor shall give notice on the date that the timeframes
expire when service authorization decisions are not reached within
the applicable timeframes for either standard or expedited service
authorizations. (42 C.F.R. § 438.404(c)(5).)
County of Fresno
22-20101 Al
Page 24 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
8) If a provider indicates, or the Contractor determines, that following
the standard service authorization timeframe could seriously
jeopardize the member's beRefi^iaFY-6 life or health or their ability
to attain, maintain, or regain maximum function, the Contractor
must make an expedited service authorization decision and provide
notice as expeditiously as the member's b8R8fi^iaryi health
condition requires and no later than 72 hours after receipt of the
request for service. (42 C.F.R. § 438.404(c)(6); 42 C.F.R. §
438.210(d)(2)(i).)
9) The Contractor may extend the 72-hour expedited service
authorization decision time period by up to 14 calendar days if the
member beRefiGiary requests an extension, or if the Contractor
justifies to the Department, upon request, a need for additional
information and how the extension is in the member's beRefiGiar
interest. (42 C.F.R. § 438.404(c)(6); 42 C.F.R. § 210(d)(2)(ii).)
10) The Contractor shall deposit the NOABD with the United States
Postal Service in time for pick-up on the date that the applicable
timeframe expires. (Cal. Code Regs., tit. 9, § 1850.210(f).)
C. The Adverse Benefit Determination shall be effective on the date of the
NOABD, and the Contractor shall mail the NOABD by the date of adverse
benefit determination when any of the following occur-
1) The death of a member beRef;^;ar„; (42 C.F.R. § 431.213(a).)
2) Receipt of a signed written member "ery statement
requesting service termination or giving information requiring
termination or reduction of services, provided the member
"e^ F�,4 understands that this will be the result of supplying that
information; (42 C.F.R. § 431.213(b)(1)-(b)(2).)
3) The member's beRefi^iary!s admission to an institution where they
are ineligible for further services; (42 C.F.R. § 431 .213(c).)
4) The member's beRefi^iary whereabouts are unknown and mail
directed to them has no forwarding address; (42 C.F.R. §
431.213(d).)
County of Fresno
22-20101 Al
Page 25 of 25
Exhibit A— Attachment 12
BENEFIGI av MEMBER PROBLEM RESOLUTION
5) Notice that the member beRefi^iary has been accepted for
Medicaid services by another local jurisdiction; (42 C.F.R. §
431.213(e).)
6) A change in the member's beRefi^i- FYLS physician's prescription for
the level of medical care; (42 C.F.R. § 431.213(f).) or
7) The notice involves an adverse determination with regard to
preadmission screening requirements of section 1919(e)(7) of the
Act. (42 C.F.R. § 431.213(g).)
8) The transfer or discharge from a facility will occur in an expedited
fashion. (42 C.F.R. § 431.213(h).)
9) Endangerment of the safety or health of individuals in the facility;
improvement in the resident's health sufficient to allow a more
immediate transfer or discharge; urgent medical needs that require
a resident's immediate transfer or discharge; or notice that a
resident has not resided in the nursing facility for 30 days (but only
in Adverse Benefit Determinations based on nursing facility
transfers).
12. Annual Grievance and Appeal Report
The Contractor is required to submit to the Department a report that summarizes
member "ery grievances, appeals and expedited appeals, in accordance
with BHIN 22-036, filed from July 1 of the previous year through June 30 of that
year by September 9Eteber 1 of each year. The report shall include the total
number of grievances, appeals, and expedited appeals by type, by subject areas
established by the Department, and by disposition. (42 C.F.R. § 438.66(e).Ca--.
Code Regsi +�t. 9 § 1 81 n 375(a
County of Fresno
22-20101 Al
Page 1 of 7
Exhibit A— Attachment 13
PROGRAM INTEGRITY
1. General Requirements
As a condition for receiving payment under a Medi-Cal managed care program,
the Contractor shall comply with the provisions of 42 C.F.R. sections 438.604,
438.606 and 438.608, and 438.610. (42 C.F.R. § 438.600(b).)
2. Periodic Audits
Contractor shall be subject to an independent audit of the accuracy,
truthfulness, and completeness of the encounter and financial data
submitted by, or on behalf of, the Contractor. The audit shall occur no less
frequently than once every three year. Commencing Fiscal Year 2023/2024,
Contractor shall comply with BHIN 23-044 and any superseding
departmental guidance. The Department or its contractor shall conduct the
audit. (42 C.F.R. § 438.602, subd. (e).)
3. Excluded Providers
A. The Contractor shall screen and periodically revalidate all network
providers in accordance with the requirements of 42 Code of Federal
Regulations, section 455, subparts B and E. (42 C.F.R. §438.602(b).)
B. Consistent with the requirements of 42 Code of Federal Regulations,
section 455.436, the Contractor must confirm the identity and determine
the exclusion status of all providers (employees and network providers)
and any subcontractor, as well as any person with an ownership or control
interest, or who is an agent or managing employee of the of the Mental
Health Plan through routine checks of Federal and State databases. This
includes the Social Security Administration's Death Master File, the
National Plan and Provider Enumeration System (NPPES), the Office of
Inspector General's List of Excluded Individuals/Entities (LEIE), the
System for Award Management (SAM), as well as the Department's Medi
Cal Suspended and Ineligible Provider List (S & I List). (42 C.F.R.
§438.602(d).)
County of Fresno
22-20101 Al
Page 2 of 7
Exhibit A— Attachment 13
PROGRAM INTEGRITY
C. If the Contractor finds a party that is excluded, it must promptly notify the
Department (42 C.F.R. §438.608(a)(2),(4)) and the Department will take
action consistent with 42 C.F.R. section 438.610((d). The Contractor shall
not certify or pay any excluded provider with Medi-Cal funds, and any
such inappropriate payments or overpayments may be subject to recovery
and/or be the basis for other sanctions by the appropriate authority.
4. Compliance Program
A. Pursuant to 42 C.F.R. section 455.1(a)(1), the Contractor must report
fraud and abuse information to the Department.
B. The Contractor, or any subcontractor, to the extent that the subcontractor
is delegated responsibility by the Contractor for coverage of services and
payment of claims under this Contract, shall implement and maintain a
compliance program designed to detect and prevent fraud, waste and
abuse that must include:
1) Written policies, procedures, and standards of conduct that
articulate the organization's commitment to comply with all
applicable requirements and standards under the contract, and all
applicable Federal and state requirements.
2) A Compliance Officer (CO) who is responsible for developing and
implementing policies, procedures, and practices designed to
ensure compliance with the requirements of the contract and who
reports directly to the CEO and the Board of Directors (BoD).
3) A Regulatory Compliance Committee (RCC) on the BoD and at the
senior management level charged with overseeing the
organization's compliance program and its compliance with the
requirements under the contract.
4) A system for training and education for the CO, the organization's
senior management, and the organization's employees for the
federal and state standards and requirements under the contract.
5) Effective lines of communication between the CO and the
organization's employees.
County of Fresno
22-20101 Al
Page 3 of 7
Exhibit A— Attachment 13
PROGRAM INTEGRITY
6) Enforcement of standards through well-publicized disciplinary
guidelines.
7) The establishment and implementation of procedures and a system
with dedicated staff for routine internal monitoring and auditing of
compliance risks, prompt response to compliance issues as they
are raised, investigation of potential compliance problems as
identified in the course of self-evaluation and audits, correction of
such problems promptly and thoroughly (or coordination of
suspected criminal acts with law enforcement agencies) to reduce
the potential for recurrence, and ongoing compliance with the
requirements under the contract. (42 C.F.R. § 438.608(a), (a)(1).)
5. Fraud Reporting Requirements
A. The Contractor, or any subcontractor, to the extent that the subcontractor
is delegated responsibility by the Contractor for coverage of services and
payment of claims under this Contract, shall implement and maintain
arrangements or procedures designed to detect and prevent fraud, waste
and abuse that include prompt reporting to the Department about the
following-
1) Any potential fraud, waste, or abuse. (42 C.F.R. § 438.608(a),
(a)(7).)
2) All overpayments identified or recovered, specifying the
overpayments due to potential fraud. (42 C.F.R. § 438.608(a),
(a)(2).)
3) Information about changes in a member's benefiGiar„!s
circumstances that may affect the member's benefiGiar"'& eligibility
including changes in the member's benefiGiar"'s residence or the
death of the member be ary. (42 C.F.R. § 438.608(a), (a)(3).)
4) Information about a change in a network provider's circumstances
that may affect the network provider's eligibility to participate in the
managed care program, including the termination of the provider
agreement with the Contractor. (42 C.F.R. § 438.608(a), (a)(4).)
County of Fresno
22-20101 Al
Page 4 of 7
Exhibit A— Attachment 13
PROGRAM INTEGRITY
B. If the Contractor identifies an issue or receives notification of a complaint
concerning an incident of potential fraud, waste or abuse, in addition to
notifying the Department, the Contractor shall conduct an internal
investigation to determine the validity of the issue/complaint, and develop
and implement corrective action, if needed.
C. The Contractor shall implement and maintain written policies for all
employees of the Mental Health Plan, and of any contractor or agent, that
provide detailed information about the False Claims Act and other Federal
and state laws, including information about rights of employees to be
protected as whistleblowers. (42 C.F.R. § 438.608(a), (a)(6).)
D. The Contractor shall implement and maintain arrangements or procedures
that include provision for the Contractor's suspension of payments to a
network provider for which there is a credible allegation of fraud. (42
C.F.R. § 438.608(a), (a)(8).)
6. Service Verification
Pursuant to 42 C.F.R. section 438.608(a)(5), the Contractor, and/or any
subcontractor, to the extent that the subcontractor is delegated responsibility by
the Contractor for coverage of services and payment of claims under this
Contract, shall implement and maintain arrangements or procedures designed to
detect and prevent fraud, waste and abuse that include provisions to verify, by
sampling or other methods, whether services that have been represented to have
been delivered by network providers were received by members beRefiGiarioo
and the application of such verification processes on a regular basis. (42 C.F.R.
§ 438.608(a), (a)(5).)
7. Disclosures
A. Disclosure of 5% or More Ownership Interest:
1) Pursuant to 42 C.F.R. section 455.104, Medicaid managed care
entities must disclose certain information related to persons who
have an ownership or control interest in the managed care entity,
as defined in 42 C.F.R. section 455.101. The parties hereby
acknowledge that because the Contractor is a political subdivision
of the State of California, there are no persons who meet such
definition and therefore there is no information to disclose.
County of Fresno
22-20101 Al
Page 5 of 7
Exhibit A— Attachment 13
PROGRAM INTEGRITY
a) In the event that, in the future, any person obtains an interest
of 5% or more of any mortgage, deed of trust, note or other
obligation secured by Contractor, and that interest equals at
least 5% of Contractor's property or assets, then the
Contractor will make the disclosures set forth in i and
subsection 2(a).
i. The Contractor will disclose the name, address, date of
birth, and Social Security Number of any managing
employee, as that term is defined in 42 C.F.R. section
455.101. For purposes of this disclosure, Contractor may
use the business address for any member of its Board of
Supervisors.
ii. The Contractor shall provide any such disclosure upon
execution of this contract, upon its extension or renewal,
and within 35 days after any change in Contractor
ownership or upon request of the Department.
2) The Contractor shall ensure that its subcontractors and network
providers submit the disclosures below to the Contractor regarding
the network providers' (disclosing entities') ownership and control.
The Contractor's network providers must be required to submit
updated disclosures to the Contractor upon submitting the provider
application, before entering into or renewing the network providers'
contracts, within 35 days after any change in the
subcontractor/network provider's ownership, annually and upon
request during the re-validation of enrollment process under 42
Code of Federal Regulations section 455.104.
a) Disclosures to be Provided:
i. The name and address of any person (individual or
corporation) with an ownership or control interest in the
network provider. The address for corporate entities
shall include, as applicable, a primary business address,
every business location, and a P.O. Box address;
ii. Date of birth and Social Security Number (in the case of
an individual);
County of Fresno
22-20101 Al
Page 6 of 7
Exhibit A— Attachment 13
PROGRAM INTEGRITY
iii. Other tax identification number (in the case of a
corporation with an ownership or control interest in the
managed care entity or in any subcontractor in which the
managed care entity has a 5 percent or more interest);
iv. Whether the person (individual or corporation) with an
ownership or control interest in the Contractor's network
provider is related to another person with ownership or
control interest in the same or any other network provider
of the Contractor as a spouse, parent, child, or sibling; or
whether the person (individual or corporation) with an
ownership or control interest in any subcontractor in
which the managed care entity has a 5 percent or more
interest is related to another person with ownership or
control interest in the managed care entity as a spouse,
parent, child, or sibling;
V. The name of any other disclosing entity in which the
Contractor or subcontracting network provider has an
ownership or control interest; and
vi. The name, address, date of birth, and Social Security
Number of any managing employee of the managed care
entity.
3) For each provider in Contractor's provider network, the Contractor
shall provide the Department with all disclosures before entering
into a network provider contract with the provider and annually
thereafter and upon request from the Department during the re-
validation of enrollment process under 42 Code of Federal
Regulations section 455.104.
B. Disclosures Related to Business Transactions — the Contractor must
submit disclosures and updated disclosures to the Department or HHS
including information regarding certain business transactions within 35
days, upon request.
1) The following information must be disclosed:
a) The ownership of any subcontractor with whom the
Contractor has had business transactions totaling more than
$25,000 during the 12-month period ending on the date of
the request; and
County of Fresno
22-20101 Al
Page 7 of 7
Exhibit A— Attachment 13
PROGRAM INTEGRITY
b) Any significant business transactions between the
Contractor and any wholly owned supplier, or between the
Contractor and any subcontractor, during the 5-year period
ending on the date of the request.
c) The Contractor must obligate Network Providers to submit
the same disclosures regarding network providers as noted
under subsection 1(a) and (b) within 35 days upon request.
C. Disclosures Related to Persons Convicted of Crimes
1) The Contractor shall submit the following disclosures to the
Department regarding the Contractor's management:
a) The identity of any person who is a managing employee of
the Contractor who has been convicted of a crime related to
federal health care programs. (42 C.F.R. § 455.106(a)(1),
(2)•)
b) The identity of any person who is an agent of the Contractor
who has been convicted of a crime related to federal health
care programs. (42 C.F.R. § 455.106(a)(1), (2).) For this
purpose, the word "agent" has the meaning described in 42
Code of Federal Regulations section 455.101.
2) The Contractor shall supply the disclosures before entering into the
contract and at any time upon the Department's request.
3) Network providers should submit the same disclosures to the
Contractor regarding the network providers' owners, persons with
controlling interest, agents, and managing employees' criminal
convictions. Network providers shall supply the disclosures before
entering into the contract and at any time upon the Department's
request.
County of Fresno
22-20101 Al
Page 1 of 3
Exhibit A— Attachment 14
REPORTING REQUIREMENTS
1. Data Submission/ Certification Requirements
A. The Contractor shall submit any data, documentation, or information
relating to the performance of the entity's obligations as required by the
State or the United States Secretary of Health and Human Services. (42
C.F.R. § 438.604(b).) The individual who submits this data to the state
shall concurrently provide a certification, which attests, based on best
information, knowledge and belief that the data, documentation and
information is accurate, complete and truthful. (42 C.F.R. § 438.606(b)
and (c).) The data, documentation, or information submitted to the state by
the Contractor shall be certified by one of the following:
1) The Contractor's Chief Executive Officer (CEO).
2) The Contractor's Chief Financial Officer (CFO).
3) An individual who reports directly to the CEO or CFO with
delegated authority to sign for the CEO or CFO so that the CEO or
CFO is ultimately responsible for the certification. (42 C.F. R. §
438.606(a).)
2. Encounter Data
The Contractor shall submit encounter data to the Department at a frequency
and level specified by the Department and CMS. (42 C.F.R. § 438.242(c)(2).)
The Contractor shall ensure collection and maintenance of sufficient member
"enr encounter data to identify the provider who delivers service(s) to the
member "ery. (42 C.F.R. § 438.242(c)(1).) The Contractor shall submit all
member "ery encounter data that the Department is required to report to
CMS under section 438.818. (42 C.F.R. § 438.242(c)(3).) The Contractor shall
submit encounter data to the state in standardized Accredited Standards
Committee (ASC) X12N 837 and National Council for Prescription Drug
Programs (NCPDP) formats, and the ASC X12N 835 format as appropriate. (42
C.F.R. § 438.242(c)(4).)
County of Fresno
22-20101 Al
Page 2 of 3
Exhibit A— Attachment 14
REPORTING REQUIREMENTS
3. Insolvency
A. The Contractor shall submit data to demonstrate it has made adequate
provision against the risk of insolvency to ensure that members
beRefiniarieS will not be liable for the Contractor's debt if the Contractor
becomes insolvent. (42 C.F.R. § 438.604(a)(4); 42 C.F.R. § 438.116.)
B. The Contractor shall meet the State's solvency standards for private
health maintenance organizations or be licensed by the State as a risk-
bearing entity, unless one of the following exceptions apply (42 C.F.R. §
438.116 (b).):
1) The Contractor does not provide both inpatient hospital services
and physician services.
2) The Contractor is a public entity.
3) The Contractor is (or is controlled by) one of more federally
qualified health centers and meets the solvency standards
established by the State for those centers.
4) The Contractor has its solvency guaranteed by the State.
4. Network Adequacy
The Contractor shall submit, in a manner and format determined by the
Department, documentation to demonstrate compliance with the Department's
requirements for availability and accessibility of services, including the adequacy
of the provider network. (42 C.F.R. § 438.604(a)(5).)
5. Information on Ownership and Control
The Contractor shall submit for state review information on its and its
subcontractors' ownership and control described in 42 C.F.R. section 455.104
and Attachment 13 of this Contract. (42 C.F.R § 438.604(a)(6).)
6. Annual Report of Overpayment Recoveries
The Contractor shall submit an annual report of overpayment recoveries in a
manner and format determined by the Department. (42 C.F.R § 438.604(a)(7).)
County of Fresno
22-20101 Al
Page 3 of 3
Exhibit A— Attachment 14
REPORTING REQUIREMENTS
7. Performance Data
A. In an effort to improve the performance of the State's managed care
program, in accordance with 42 Code of Federal Regulations section
438.66(c), the Contractor will submit the following to the Department (42
C.F.R. § 438.604(b).):
1) Enrollment and disenrollment data;
2) Member grievance and appeal logs;
3) Provider complaint and appeal logs;
4) The results of any member beRefiGiar„ satisfaction survey;
5) The results of any provider satisfaction survey;
6) Performance on required quality measures;
7) Medical management committee reports and minutes;
8) The Contractor's annual quality improvement plan;
9) Audited financial and encounter data; and
10) Customer service performance data.
B. The Contractor shall cooperate with DHCS to provide and report quality
measures per the 1915(b) Special Terms and Conditions and the
Comprehensive Quality Strategy.
8. Parity in Mental Health and Substance Use Disorder Services
The Contractor shall submit to the Department, upon request, any policies and
procedures or other documentation necessary for the State to establish and
demonstrate compliance with Title 42 of the Code of Federal Regulations, part
438, subpart K, regarding parity in mental health and substance use disorder
benefits.
County of Fresno
22-20101 Al
Page 1 of 2
Exhibit A— Attachment 15
PEER SUPPORT SERVICES
MEDI-CAL PEER SUPPORT SERVICES
1. The Contractor has taken the option to implement Medi-Cal Peer Support
Services.
2. The Contractor shall provide, or arrange, and pay for Peer Support Services to
Medi-Cal members beRefi^iaFi . Contractor's provision of Peer Support
Services shall conform to the requirements of Supplement 3 to Attachment 3.1-A
and Supplement 3 to Attachment 3.1-B of the California State Plan. Contractor's
provision of Peer Support Services and implementation of a Medi-Cal Peer
Support Specialist Certification Program shall further conform to the applicable
requirements of Behavioral Health Information Notice (BHIN) 21-041 and to the
requirements in any subsequent BHINs issued by the Department pursuant to
W&I Code section 14045.21.
3. Voluntary Participation and Funding
The Contractor shall fund the nonfederal share of any applicable expenditures,
since the Contractor has opted to implement Peer Support Services and
participate in the Peer Support Specialist Certification Program set forth in Article
1.4 of Chapter 7, Part 3, of Division 9 of the Welfare and Institutions Code. The
Contractor's local share utilized to fund Peer Support Services and the
Contractor's participation in the Peer Support Specialist Certification Program
shall not be considered an increase in costs mandated by the 2011 realignment
legislation.
4. Provision of Peer Support Services
Peer Support Services may be provided face-to-face, by telephone or by
telehealth with the member beRefiGiary or significant support person(s) and may
be provided anywhere in the community.
5. Peer Support Specialists
Contractor shall ensure that Peer Support Services are provided by certified Peer
Support Specialists as established in BHIN 21-041.
6. Behavioral Health Professional and Peer Support Specialist Supervisors
The Contractor shall ensure that Peer Support Specialists provide services under
the direction of a Behavioral Health Professional.
County of Fresno
22-20101 Al
Page 2 of 2
Exhibit A— Attachment 15
PEER SUPPORT SERVICES
A Behavioral Health Professional must be licensed, waivered, or registered in
accordance with applicable State of California licensure requirements and listed
in the California Medicaid State Plan as a qualified provider of SMHS, DMC-
ODS, or DMC.
Peer Support Specialists may also be supervised by Peer Support Specialist
Supervisors, as established in BHIN 21-041.
7. Practice Guidelines
Counties shall require Peer Support Specialists to adhere to the practice
guidelines developed by the Substance Abuse and Mental Health Services
Administration, What are Peer Recovery Support Services (Center for Substance
Abuse Treatment, What are Peer Recovery Support Services? HHS Publication
No.(SMA) 09-4454. Rockville, MD: Substance Abuse and Mental Health Services
Administration, U.S. Department of Health and Human Services), which may be
accessed electronically through the following Internet World Wide Web
connection: www.samhsa.gov/resource/ebp/what-are-peer-recovery-support-
services.
8. Contractor shall oversee and enforce the certification standards and
requirements set forth in Article 1.4 of Chapter 7, Part 3, of Division 9 of the
Welfare and Institutions Code and departmental guidance, including BHIN 21-
041. Contractor shall ensure that the Medi-Cal Peer Support Specialist
Certification Program:
a. Submits to the department a peer support specialist program plan in
accordance with Enclosure 2 of BHIN 21-041 describing how the peer
support specialist program will meet all of the federal and state
requirements for the certification and oversight of peer support specialists.
b. Participates in periodic reviews conducted by the department to ensure
adherence to all federal and state requirements.
c. Submits annual peer support specialist program reports to the department
in accordance with Enclosure 5 of BHIN 21-041. Reports shall cover the
fiscal year and shall be submitted by the following December 31St
County of Fresno
22-20101 Al
Page 1 of 7
Exhibit B
BUDGET DETAIL AND PAYMENT PROVISIONS
1. Medical Assistance Payment Provisions
The Department will reimburse the Contractor for Specialty Mental Health
Services provided pursuant to the requirements in Exhibit A to this
contract, based upon a fee schedule developed by the Department and
specified in the approved Medicaid State plan and waivers. This program
p eni ie F Rd 201 'I fi RGIS from the Men Health
E�� L�ea�e�F , �v-rcrrtAiTrcaTcrr
SeFViGes F RGIe and aRy a+her fi Rds from which the ('en+reller males
0RG diRg Wolf. & Inc+ ( Gde §§ 5891 , 5992 and 14705(a)2). These fi indiRg
oei ernes may he used by the ('en+ran+er +e nazi for ceFVines and then nor+if y as
pblip eXpeRGIO irec in erder to he reimhi irseid federal fi inrlo
2. Budget Contingency Clause
This provision is a supplement to provision number nine (Federal Contract
Funds) in Exhibit D(F) which is attached hereto as part of this Contract.
A. Federal Budget
If federal funding for FFP reimbursement in relation to this contract is
eliminated or substantially reduced by Congress, the Department and the
Contractor each shall have the option either to cancel this contract or to
propose a contract amendment to address changes to the program
required as a result of the elimination or reduction of federal funding.
B. Delayed Federal Funding
The Contractor and the Department agree to consult with each other on
interim measures for program operation that may be required to maintain
adequate services to membershenefi^iarieS in the event that there is
likely to be a delay in the availability of federal funding.
3. Federal Financial Participation
Nothing in this contract shall limit the Contractor's ability to submit claims for
appropriate FFP reimbursement based en aGtual total fund expeRdit Tres for any
County of Fresno
22-20101 Al
Page 2 of 7
Exhibit B
BUDGET DETAIL AND PAYMENT PROVISIONS
covered services, of quality assurance and, utilization review, Medi-Cal
Administrative Activities and/or administrative costs. In accordance with the
Welf. & Inc+ Code son+ien 14705(c the Contractor shall ensure compliance with
all requirements necessary for Medi-Cal reimbursement for these services and
activities, including the requirements in Welfare & Institutions (W&I) Code,
section 14184.403. Claims for FFP reimbursement shall be submitted by the
Contractor to the Department for adjudication throughout the fiscal year.
state that it has ORG FFed p blin expenditures prior to requesting the
reomb irsomont of federal fi lRds
4. Audits and Recovery of Overpayments
A. Pursuant to Welf. & Inst. Code section 14707, in the case of federal audit
exceptions, the Department will follow federal audit appeal processes
unless the Department, in consultation with the County Behavioral Health
Director's Association of California, determines that those appeals are not
cost beneficial.
1) Whenever there is a final federal audit exception against the State
resulting from a claim for expenditure of federal funds fey are
expenditure by individual counties that is not federally allowable,
the department may offset federal reimbursement and request the
Controller's office to offset the distribution of funds to the Contractor
from the Mental Health Subaccount, the Mental Health Equity
Subaccount and the Vehicle License Collection Account of the
Local Revenue Fund; funds from the Mental Health Account and
the Behavioral Health Subaccount of the Local Revenue Fund
2011 ; and any other mental health realignment funds from which
the Controller makes distributions to the counties by the amount of
the exception. The Department shall provide evidence to the
Controller that the county had been notified of the amount of the
audit exception no less than 30 days before the offset is to occur.
2) The Department will involve the Contractor in developing responses
to any draft federal audit reports that directly impact the county.
B. Pursuant to W&I Code section 14718(b)(2), the Department may offset the
amount of any federal disallowance, audit exception, or overpayment
against subsequent claims from the Contractor.
County of Fresno
22-20101 Al
Page 3 of 7
Exhibit B
BUDGET DETAIL AND PAYMENT PROVISIONS
1) The department may offset the acne in+ of any state
ce, audit exce on,wan disallvo dit pti or overpayment for fisnal deers
r�c�irai�
through and innli ding 2010 11 against subsequent nlaims from the
GentrraGcove
1) Offsets may be done at any time, after the department has invoiced
or otherwise notified the Contractor about the audit exception,
disallowance, or overpayment. The Department shall determine the
amount that may be withheld from each payment to the mental
health plan.
2) The maximum withheld amount shall be 25 percent of each
payment as long as the Department is able to comply with the
federal requirements for repayment of FFP pursuant to 42 United
States Code (U.S.C.) §1396b(d)(2)). The Department may increase
the maximum amount when necessary for compliance with federal
laws and regulations.
C. Pursuant to the W&I Code section 14170 and 42 C.F.R. section 438.602,
Gest rener+s data submitted to the Department are subject to audit in the
manner and form prescribed by the Department. The year end Gos+ report
shall innli de both GORtranter's oos+s and the nests of its si ibnon+ranters if
e
aft Contractor and its subcontractors shall be subject to audits and/or
reviews, including client record reviews, by the Department. In
accordance with the W&I Code § 14170, any audit of Contractor's cost
re� data shall occur within three years of the date of receipt by the
Department of the final GOst roper+ with signed certification by the
Contractor's Mental Health Director or an individual who has delegated
authority to sign for, and reports directly to the Contractor's Mental
Health Director. and one of the following: (1) the Gentranter's chief
FinanGial OffiG8r (er equivalent), M\ an individual who has delegated
autherity t SigR fer, and reports diren i +e the Gentry is (chief Finannial
, vrco�rrvv vZrrc-vvrrcru vrrr�crr
Offiner, er (3) the noUnty auditor nentreller, er egg Bivalent A signatures is
a-re required before the data it the Gest roper+ shall be considered
final. For purposes of this section, the GOSt�n data shall be
considered audited once the Department has informed the Contractor of
its intent to make adjustments dosallo,e, /+osts on the Gest report or once
the Department has informed the Contractor of its intent to close the audit
without idisallewannes
County of Fresno
22-20101 Al
Page 4 of 7
Exhibit B
BUDGET DETAIL AND PAYMENT PROVISIONS
D. If the adjustments result in the Department owing €-F-P payments to the
Contractor, the Department shall submit a claim to the federal government
for the related FFP within 30 days contingent upon sufficient budget
authority.
5. Claims Adjudication Process
A. IR Y,,�,�,.,Ge with the W Q IRSt. Gede 68GtiE)R14705(G), nlaims
rrrcreeeYd�c c �.. cr��n-rr�
Pursuant to W&I Code section 14184.403, claims for Medicaid
reimbursement federal f Undo OR reimb F%Ment for cer—.. shall comply
with eligibility and service requirements under applicable federal and state
law.
B. The Contractor shall certify each claim submitted to the Department in
accordance with Cal. Code Regs., tit. 9, section 1840.112 and 42 C.F.R.
section 433.51, at the time the claims are submitted to the Department.
The CE)Rtraoter'c Chief FlnaRGial Offiner or their eq iiyaleRt er an iRdiyid gal
e
SigR
with autherity delegated by the GOi Rty ai diter_n� lle�hall r theGertifination, denlarriiri-g, Unde"r^renolty of perjury, that the GORtronter has
0RGu f aR expeeRdituree--tO GOver crthe ervineces ORGlcludeed OR the nlocrairns to
satisfy the req iiremento for FF- . The Contractor's Mental Health Director
or an individual with authority delegated by the Mental Health Director
shall sign the certification, declaring, under penalty of perjury that, to the
best of their knowledge and belief, the claim is in all respects true, correct,
and in accordance with the law and meets the requirements of Cal. Code
Regs., tit. 9, section 1840.112(b) and 42 C.F.R. sections 438.604 and
438.606. The Contractor shall have mechanisms that support the Mental
Health Director's certification, including the certification that the services
for which claims were submitted were actually provided to the
memberhenry. If the Department requires additional information
from the Contractor that will be used to establish Department payments to
the Contractor, the Contractor shall certify that the additional information
provided is in accordance with 42 C.F.R. section 438.604.
C. The Contractor shall certify that any funds transferred to the
Department by the Contractor qualify for federal financial
participation pursuant to 42 CFR section 433.51, any other applicable
federal Medicaid laws, and the CalAIM Special Terms and Conditions,
and are not derived from impermissible sources such as recycled
County of Fresno
22-20101 Al
Page 5 of 7
Exhibit B
BUDGET DETAIL AND PAYMENT PROVISIONS
Medicaid payments, Federal money excluded from use as State
match, impermissible taxes, and non-bona fide provider-related
donations. Impermissible sources do not include revenue relating to
patient care or other revenue received from federal health care
programs to the extent that the program revenue is not obligated to
the State as the source of funding.
The Contractor shall certify each claim submitted to the Department
in accordance with 9 California Code of Regulations (CCR), section
1840.112 and 42 CFR sections 438.604, 438.606 and 438.608. The
Contractor's Mental Health Director or an individual with authority
delegated by the Mental Health Director shall sign the certification,
declaring under penalty of perjury that, to the best of their
knowledge and belief, the claim in all respects is true, correct, and in
accordance with the law and meets the requirements of 9 CCR
section 1840.112 and 42 CFR sections 438.604 and 438.606. The
Contractor shall have mechanisms that support the Mental Health
Director's certification, including the certification that the services
for which claims were submitted were actually provided to the
member. If the Department requires additional information from the
Contractor that will be used to establish Department payments to the
Contractor, the Contractor shall certify that the additional
information provided is in accordance with 42 CFR, section 438.604.
D. Claims not meeting federal and/or state requirements shall be returned to
Contractor as not approved for payment, along with a reason for denial.
Claims meeting all Health Insurance Portability and Accountability Act
(HIPAA) transaction requirements and any other applicable federal or
state privacy laws or regulations and certified by the Contractor in
accordance with Cal. Code Regs., tit. 9, §1840.112 subsections (a), (b),
and d shall be processed for adjudication.
E. Good cause justification for late claim submission is governed by
applicable federal and state laws and regulations and is subject to
approval by the Department.
F. In the event that the Department or the Contractor determines that
changes requiring a change in the Contractor's or Department's obligation
must be made relating to either the Department's or the Contractor's
claims submission and adjudication systems due to federal or state law
County of Fresno
22-20101 Al
Page 6 of 7
Exhibit B
BUDGET DETAIL AND PAYMENT PROVISIONS
changes or business requirements, both the Department and the
Contractor agree to provide notice to the other party as soon as
practicable prior to implementation. This notice shall include information
and comments regarding the anticipated requirements and impacts of the
projected changes. The Department and the Contractor agree to meet
and discuss the design, development, and costs of the anticipated
changes prior to implementation.
G. The (;ORtFaGtE)F shall comply with Cal. Gede eys•e `tee e
wh hmittiRg aiMS for FFD fer ceFVines hill by inrdiyirdi al er grei in
�,�e��I��C�-�„-r,��, �-�-�����Red-aye
providers. The (`E)ntrnntnr Shall submit SeFViGe Gedec from the Health
Care PFOGedWe GediRg System (I-IGPGS) published in the meet GUFFe Rt
M8Rtal Health Merdi Cal hilliRg mane al
6. Payment Data Certification
The Contractor shall certify the data it provides to the Department to be used in
determining payment of FFP to the Contractor, in accordance with 42 C.F.R.
sections 438.604 and 438.606.
7. System Changes
In the event changes in federal or state law or regulations, including court
decisions and interpretations, necessitate a change in either the fiscal or program
obligations or operations of the Contractor or the Department, or a change in
obligation for the GGSt of nreyidinn payment of covered services the Department
and the Contractor agree to negotiate, pursuant to the W&I Code section
14714(c) regarding (a) changes required to remain in compliance with the new
law or changes in existing obligations, (b) projected programmatic and fiscal
impacts, (c) necessary contract amendments. To the extent that contract
amendments are necessary, the parties agree to act to ensure appropriate
amendments are made to accommodate any changes required by law or
regulation.
8. Administrative Reimbursement
A. The Contractor may submit claims for reimbursement of Medical
Administrative Activities (MAA) pursuant to W&I Code section 14132.47.
The Contractor shall not submit claims for MAA unless it has submitted a
claiming plan to the Department which was approved by the Department
County of Fresno
22-20101 Al
Page 7 of 7
Exhibit B
BUDGET DETAIL AND PAYMENT PROVISIONS
and is effective during the quarter in which the costs being claimed were
incurred. In addition, the Contractor shall not submit claims for
reimbursements of MAA that are not consistent with the Contractor's
approved MAA claiming plan. The Contractor shall not use the relative
value methodology to report its MAA costs on the year-end cost report.
Rather, the Contractor shall calculate and report MAA units on the cost
report by multiplying the amount of time (minutes, hours, etc.) spent on
MAA activities by the salary plus benefits of the staff performing the
activity and then allocating indirect administrative and other appropriately
allocated costs.
B. Di�aant W the Welf. 12. IRSt GE) de § 1 471 1(G) Administrative costs shall
be claimed separately in a manner consistent with federal Medicaid
requirements and the approved Medical Assistance Program Cost
Allocation Medicaid state plans and waivers and shall be limited to 15
percent of the total actual payments for chef direct client services. The
cost of performing quality assurance and utilization review activities shall
be reimbursed separately and shall not be included in administrative
costs.
9. Notification of Request for Contract Amendment
In addition to the provisions in Exhibit E, Additional Provisions, both
parties agree to notify the other party whenever an amendment to this
contract is to be requested so that informal discussion and consultation
can occur prior to a formal amendment process.
County of Fresno
22-20101 Al
Page 1 of 17
Exhibit E
ADDITIONAL PROVISIONS
1. Amendment Process
Should either party, during the term of this Contract, desire a change or
amendment to the terms of this Contract, such changes or amendments shall be
proposed in writing to the other party, who will respond in writing as to whether
the proposed changes/amendments are accepted or rejected. If accepted and
after negotiations are concluded, the agreed upon changes shall be made
through the State's official agreement amendment process. No amendment will
be considered binding on either party until it is formally approved by both parties
and the Department of General Services (DGS), if DGS approval is required.
2. Cancellation/Termination
A. General Provisions
1) As required by, if the Contractor decides not to contract with the
Department, does not renew its contract, or is unable to meet the
standards set by the Department, the Contractor agrees to inform
the Department of this decision in writing. (W&I Code §
14712(c)(1).)
2) If the Contractor is unwilling to contract for the delivery of specialty
mental health services or if the Department or Contractor
determines that the Contractor is unable to adequately provide
specialty mental health services or that the Contractor does not
meet the standards the Department deems necessary for a mental
health plan, the Department shall ensure that specialty mental
health services are provided to Medi-Cal members benefiGiario�
(W&I Code § 147122(c)(2), (3).)
3) The Department may contract with qualifying individual counties,
counties acting jointly, or other qualified entities approved by the
Department for the delivery of specialty mental health services in
any county that is unable or unwilling to contract with the
Department. The Contractor may not subsequently contract to
provide specialty mental health services unless the Department
elects to contract with the Contractor. (W&I Code § 147122(c)(4).)
4) If the Contractor does not contract with the Department to provide
specialty mental health services, the Department will work with the
Department of Finance and the Controller to obtain funds from the
Contractor in accordance with Government (Govt.) Code 30027.10.
(W&I Code § 147122(d).)
County of Fresno
22-20101 Al
Page 2 of 17
Exhibit E
ADDITIONAL PROVISIONS
A. Contract Renewal
1) This contract may be renewed if the Contractor continues to meet
the requirements of Chapter 8.9 of Part 3 of Division 9 of the W&I
Code and implementing regulatory requirements, as well as the
terms and conditions of this contract. Failure to meet these
requirements shall be cause for nonrenewal of the contract. (42
C.F.R. § 438.708; W&I Code § 14714(b)(1).) The Department may
base the decision to renew on timely completion of a mutually
agreed-upon plan of correction of any deficiencies, submissions of
required information in a timely manner, and/or other conditions of
the contract. (W&I Code § 14714(b)(1).)
2) In the event the contract is not renewed based on the reasons
specified in (1), the Department will notify the Department of
Finance, the fiscal and policy committees of the Legislature, and
the Controller of the amounts to be sequestered from the Mental
Health Subaccount, the Mental Health Equity Account, and the
Vehicle License Fee Collection Account of the Local Revenue Fund
and the Mental Health Account and the Behavioral Health
Subaccount of the Local Revenue Fund 2011, and the Controller
will sequester those funds in the Behavioral Health Subaccount
pursuant to Govt. Code § 30027.10. Upon this sequestration, the
Department will use the funds in accordance with Govt. Code §
30027.10. (W&I Code § 14714(b)(2).)
B. Contract Amendment Negotiations
Should either party during the life of this contract desire a change in this
contract, such change shall be proposed in writing to the other party. The
other party shall acknowledge receipt of the proposal in writing within 10
days and shall have 60 days (or such different period as the parties
mutually may set) after receipt of such proposal to review and consider the
proposal, to consult and negotiate with the proposing party, and to accept
or reject the proposal. Acceptance or rejection may be made orally within
the 60-day period and shall be confirmed in writing within five days
thereafter. The party proposing any such change shall have the right to
withdraw the proposal at any time prior to acceptance or rejection by the
other party. Any such proposal shall set forth a detailed explanation of the
reason and basis for the proposed change, a complete statement of costs
and benefits of the proposed change and the text of the desired
amendment to this contract that would provide for the change. If the
proposal is accepted, this contract shall be amended to provide for the
County of Fresno
22-20101 Al
Page 3of17
Exhibit E
ADDITIONAL PROVISIONS
change mutually agreed to by the parties on the condition that the
amendment is approved by the Department of General Services, if
necessary.
C. Contract Termination
The Contractor may terminate this contract in accordance with, Cal. Code
Regs., tit. 9, section 1810.323(a). The Department may terminate this
contract in accordance with W&I Code, sections 14197.7, 14714 and Cal.
Code Regs., tit. 9, section 1810.323.
1) DHCS shall terminate this contract if the United States Secretary of
Health and Human Services has determined the Contractor does
not meet the requirements for participation in the Medicaid program
contained in Subchapter XIX (commencing with Section 1396) of
Chapter 7 of Title 42 of the United States Code. (W&I Code §
14197.7(i))
2) DHCS reserves the right to cancel or terminate this Contract if
DHCS finds that Contractor fails to comply with contract
requirements, state or federal law or regulations, or the state plan
or approved waivers, or for other good cause. (W&I Code §
14197.7(a))
3) Good cause includes, but is not limited to, a finding of deficiency
that results in improper denial or delay in the delivery of health care
services, potential endangerment to patient care, disruption in the
contractor's provider network, failure to approve continuity of care,
that claims accrued or to accrue have not or will not be
recompensed, or a delay in required contractor report to the
department. (W&I Code § 14197.7(a))
4) Contract termination or cancellation shall be effective as of the date
indicated in DHCS' notification to the Contractor, unless Contractor
appeals the termination, or termination is immediate pursuant to
paragraph 8. The notice shall identify any final performance,
invoicing or payment requirements.
5) Contractor may appeal contract termination pursuant to W&I Code
sections 14197.7(1)(2) or section 14714(d).
County of Fresno
22-20101 Al
Page 4 of 17
Exhibit E
ADDITIONAL PROVISIONS
6) Upon receipt of a notice of termination or cancellation, the
Contractor shall take immediate steps to stop performance and to
cancel, or if cancelation is not possible reduce, subsequent contract
costs.
7) In the event of early termination or cancellation, the Contractor shall
be entitled to payment for all allowable costs authorized under this
Contract and incurred up to the date of termination or cancellation,
including authorized non-cancelable obligations, provided such
expenses do not exceed the stated maximum amounts payable.
8) The Department will immediately terminate this Contract if the
Department finds that there is an immediate threat to the health and
safety of Medi-Cal members beRefiGiaFi . Termination of the
contract for other reasons will be subject to reasonable notice to the
Contractor of the Department's intent to terminate, as well as
notification to affected members beRefiGiari (W&I Code §
14714(d).)
D. Termination of Obligations
1) All obligations to provide covered services under this contract shall
automatically terminate on the effective date of any termination of
this contract. The Contractor shall be responsible for providing
covered services to members benefiGiari until the termination or
expiration of the contract and shall remain liable for the processing
and payment of invoices and statements for covered services
provided to members benefiGiarioo prior to such expiration or
termination.
2) When the Contractor terminates a subcontract with a provider, the
Contractor shall make a good faith effort to provide notice of this
termination, within 15 days, to the persons that the Contractor,
based on available information, determines have recently been
receiving services from that provider.
E. Contract Disputes
Should a dispute arise between the Contractor and the Department
relating to performance under this contract, other than disputes governed
by a dispute resolution process in Chapter 11 of Division 1, California
Code of Regulations, title 9, or the processes governing the audit appeals
process in Chapter 9 of Division 1 , California Code of Regulations, title 9
County of Fresno
22-20101 Al
Page 5of17
Exhibit E
ADDITIONAL PROVISIONS
the Contractor shall follow the Dispute Resolution Process outlined in
provision number 15 of Exhibit D(F) which is attached hereto as part of
this contract.
3. Fulfillment of Obligation
No covenant, condition, duty, obligation, or undertaking continued or made a part
of this contract shall be waived except by written agreement of the parties hereto,
and forbearance or indulgence in any other form or manner by either party in any
regard whatsoever will not constitute a waiver of the covenant, condition, duty,
obligation, or undertaking to be kept, performed or discharged by the party to
which the same may apply. Until performance or satisfaction of all covenants,
conditions, duties, obligations, and undertakings is complete, the other party shall
have the right to invoke any remedy available under this contract, or under law,
notwithstanding such forbearance or indulgence.
4. Additional Provisions
A. Inspection Rights/Record Keeping Requirements
1) Provision number seven (Audit and Record Retention) of Exhibit
D(F), which is attached hereto as part of this Contract, supplements
the following requirements.
2) The Contractor, and subcontractors, shall allow the Department,
CMS, the Office of the Inspector General, the Comptroller General
of the United States, and other authorized federal and state
agencies, or their duly authorized designees, to evaluate
Contractor's, and subcontractors', performance under this contract,
including the quality, appropriateness, and timeliness of services
provided, and to inspect, evaluate, and audit any and all records,
documents, and the premises, equipment and facilities maintained
by the Contractor and its subcontractors pertaining to such services
at any time. The Contractor shall allow such inspection, evaluation
and audit of its records, documents and facilities, and those of its
subcontractors, for 10 years from the term end date of this Contract
or in the event the Contractor has been notified that an audit or
investigation of this Contract has been commenced, until such time
as the matter under audit or investigation has been resolved,
including the exhaustion of all legal remedies, whichever is later.
(See 42 C.F.R. §§ 438.3(h), 438.230(c)(3)(i-iii).) Records and
documents include but are not limited to all physical and electronic
records and documents originated or prepared pursuant to
County of Fresno
22-20101 Al
Page 6 of 17
Exhibit E
ADDITIONAL PROVISIONS
Contractor's or subcontractor's performance under this Contract
including working papers, reports, financial records and documents
of account, memberbenefiGiary records, prescription files,
subcontracts, and any other documentation pertaining to covered
services and other related services for members benefiGiar;o�
3) The Contractor, and subcontractors, shall retain, all records and
documents originated or prepared pursuant to the Contractor's or
subcontractor's performance under this Contract, including
memberbeRefiGiary grievance and appeal records identified in
Attachment 12, Section 2 and the data, information and
documentation specified in 42 Code of Federal Regulations parts
438.604, 438.606, 438.608, and 438.610 for a period of no less
than 10 years from the term end date of this Contract or in the
event the Contractor has been notified that an audit or investigation
of this Contract has been commenced, until such time as the matter
under audit or investigation has been resolved, including the
exhaustion of all legal remedies, whichever is later. (42 C.F.R. §
438.3(u); See also § 438.3(h).) Records and documents include but
are not limited to all physical and electronic records and documents
originated or prepared pursuant to the Contractor's or
subcontractor's performance under this Contract including working
papers, reports, financial records and documents of account,
memberbenefiGiary records, prescription files, subcontracts, and
any other documentation pertaining to covered services and other
related services for members benefiGiario�
B. Notices
Unless otherwise specified in this contract, all notices to be given under
this contract shall be in writing and shall be deemed to have been given
when mailed, to the Department or the Contractor at the following
addresses, unless the contract explicitly requires notice to another
individual or organizational unit:
Department of Health Care Services County of Fresno
Medi-Cal Behavioral Health Division 1925 E. Dakota Ave.
1501 Capitol Avenue, MS 2702 Fresno, CA 93726
Sacramento, CA 95814
County of Fresno
22-20101 Al
Page 7 of 17
Exhibit E
ADDITIONAL PROVISIONS
C. Nondiscrimination
1) Consistent with the requirements of applicable federal law, such as
42 Code of Federal Regulations, part 438.3(d)(3) and (4), and
state law, the Contractor shall not engage in any unlawful
discriminatory practices in the admission of members beRefiGiaFio�
assignments of accommodations, treatment, evaluation,
employment of personnel, or in any other respect any ground
protected under federal or state law, including sex, race, color,
gender, gender identity, religion, marital status, national origin,
ethnic group identification, ancestry, age, sexual orientation,
medical condition, genetic information, or mental or physical
handicap or disability. (42 U.S.C. § 18116; 42 C.F.R. § 438.3(d)(3-
4); 45 C.F.R. § 92.2; Gov. Code § 11135(a); W&I Code
§ 14727(a)(3).)
2) The Contractor shall comply with the provisions of Section 504 of
the Rehabilitation Act of 1973, as amended (codified at 29 U.S.C. §
794), prohibiting exclusion, denial of benefits, and discrimination
against qualified individuals with a disability in any federally
assisted programs or activities, and shall comply with the
implementing regulations in Parts 84 and 85 of Title 45 of the
C.F.R., as applicable.
3) The Contractor shall include the nondiscrimination and compliance
provisions of this contract in all subcontracts to perform work under
this contract.
D. Relationship of the Parties
The Department and the Contractor are, and shall at all times be deemed
to be, independent agencies. Each party to this contract shall be wholly
responsible for the manner in which it performs the obligations and
services required of it by the terms of this contract. Nothing herein
contained shall be construed as creating the relationship of employer and
employee, or principal and agent, between the parties or any of their
agents or employees. Each party assumes exclusively the responsibility
for the acts of its employees or agents as they relate to the services to be
provided during the course and scope of their employment. The
Department and its agents and employees shall not be entitled to any
rights or privileges of the Contractor's employees and shall not be
considered in any manner to be Contractor employees. The Contractor
County of Fresno
22-20101 Al
Page 8 of 17
Exhibit E
ADDITIONAL PROVISIONS
and its agents and employees, shall not be entitled to any rights or
privileges of state employees and shall not be considered in any manner
to be state employees.
E. Waiver of Default
Waiver of any default shall not be deemed to be a waiver of any
subsequent default. Waiver of breach of any provision of this contract
shall not be deemed to be a waiver of any other or subsequent breach,
and shall not be construed to be a modification of the terms of this
contract.
5. Duties of the State
In discharging its obligations under this contract, and in addition to the obligations
set forth in other parts of this contract, the Department shall perform the following
duties:
A. Payment for Services
The Department shall make the appropriate payments set forth in Exhibit
B and take all available steps to secure and pay FFP to the Contractor,
once the Department receives FFP, for claims submitted by the
Contractor. The Department shall notify Contractor and allow Contractor
an opportunity to comment to the Department when questions are posed
by CMS, or when there is a federal deferral, withholding, or disallowance
with respect to claims made by the Contractor.
B. Reviews
The Department shall conduct reviews of access to and quality of care in
the Contractor's county at least once every three years and issue reports
to the Contractor detailing findings, recommendations, and corrective
action, as appropriate, pursuant to Cal. Code Regs., tit. 9, section
1810.380, subdivision (a), and W&I Code § 14197.7. The Department
shall also arrange for an annual external quality review of the Contractor
as required by 42 Code of Federal Regulations, part 438.350 and Cal.
Code Regs., tit. 9, section 1810.380(a)(7).
County of Fresno
22-20101 Al
Page 9 of 17
Exhibit E
ADDITIONAL PROVISIONS
C. Monitoring for Compliance
When monitoring activities identify areas of non-compliance, the
Department shall issue reports to the Contractor detailing findings,
recommendations, and corrective action. Failure to comply with required
corrective action could lead to civil penalties, as appropriate, pursuant to
W&I Code § 14197.7.
D. The Contractor shall prepare and submit a report to the Department that
provides information for the areas set forth in 42 C.F.R. § 438.66(b) and
(c) as outlined in Exhibit A, Attachment 14, Section 7, in the manner
specified by the Department.
E. If the Contractor has not previously implemented a Mental Health Plan or
Contractor will provide or arrange for the provision of covered benefits to
new eligibility groups, then the Contractor shall develop an Implementation
Plan (as defined in Cal. Code Regs., tit. 9, § 1810.221) that is consistent
with the readiness review requirements set forth in 42 Code of Federal
Regulations, part 438.66(d)(4), and the requirements of Cal. Code Regs.,
tit. 9, § 1810.310 (a). (See 42 C.F.R. § 438.66(d)(1), (4).) The
Department shall review and either approve, disapprove, or request
additional information for each Implementation Plan. Notices of Approval,
Notices of Disapproval and requests for additional information shall be
forwarded to the Contractor within 60 days of the receipt of the
Implementation Plan. (Cal. Code Regs., tit. 9, § 1810.310(b).) A
Contractor shall submit proposed changes to its approved Implementation
Plan in writing to the Department for review. A Contractor shall submit
proposed changes in the policies, processes or procedures that would
modify the Contractor's current Implementation Plan prior to implementing
the proposed changes.(See Cal. Code Regs., tit. 9, § 1810.310 (b)-(c)).
F. The Department shall act promptly to review the Contractor's Cultural
Competence Plan submitted pursuant to Cal. Code Regs., tit. 9, §
1810.410. The Department shall provide a Notice of Approval or a Notice
of Disapproval, including the reasons for the disapproval, to the Contractor
within 60 calendar days after receipt of the plan from the Contractor. If the
Department fails to provide a Notice of Approval or Disapproval, the
Contractor may implement the plan 60 calendar days from its submission
to the Department.
County of Fresno
22-20101 Al
Page 10 of 17
Exhibit E
ADDITIONAL PROVISIONS
G. Certification of Organizational Provider Sites Owned or Operated by the
Contractor
1) The Department shall certify the organizational provider sites that
are owned, leased or operated by the Contractor, in accordance
with Cal. Code Regs., tit. 9, section 1810.435, and the
requirements specified in Exhibit A, Attachment 8, Section 8 of this
contract. This certification shall be performed prior to the date on
which the Contractor begins to deliver services under this contract
at these sites and once every three years after that date, unless the
Department determines an earlier date is necessary. The on-site
review required by Cal. Code Regs., tit. 9, § 1810.435(e), shall be
conducted of any site owned, leased, or operated by the Contractor
and used for to deliver covered services to members beRefiGiaFio�
except that on-site review is not required for public school or
satellite sites.
2) The Department may allow the Contractor to begin delivering
covered services to members beRefiGiari at a site subject to on-
site review by the Department prior to the date of the on-site
review, provided the site is operational and has any required fire
clearances. The earliest date the Contractor may begin delivering
covered services at a site subject to on site review by the
Department is the date the Contractor requested certification of the
site in accordance with procedures established by the Department,
the date the site was operational, or the date a required fire
clearance was obtained, whichever date is latest.
3) The Department may allow the Contractor to continue delivering
covered services to members benefiGiarioo at a site subject to on-
site review by the Department as part of the recertification process
prior to the date of the on-site review, provided the site is
operational and has all required fire clearances.
4) Nothing in this section precludes the Department from establishing
procedures for issuance of separate provider identification numbers
for each of the organizational provider sites operated by the
Contractor to facilitate the claiming of FFP by the Contractor and
the Department's tracking of that information.
County of Fresno
22-20101 Al
Page 11 of 17
Exhibit E
ADDITIONAL PROVISIONS
H. Excluded Providers
1) If the Department learns that the Contractor has a prohibited
affiliation, as described in Attachment 1, Section 2, the Department:
a) Must notify the Secretary of the noncompliance.
b) May continue an existing agreement with the Contractor
unless the Secretary directs otherwise.
c) May not renew or otherwise extend the duration of an
existing agreement with the Contractor unless the Secretary
provides to the State and to Congress a written statement
describing compelling reasons that exist for renewing or
extending the agreement despite the prohibited affiliations.
d) Nothing in this section must be construed to limit or
otherwise affect any remedies available to the U.S. under
sections 1128, 1128A or 1128B of the Act. (42 C.F.R.
§438.61 0(d).)
I. Sanctions
The Department shall conduct oversight in accordance with Cal. Code
Regs., tit. 9, §§ 1810.380(a) and impose sanctions on the Contractor for
violations of the terms of this contract, and applicable federal and state
law and regulations, or the state plan or approved waivers, or for other
good cause in accordance with W&I Code § 14197.7 and guidance issued
by the Department pursuant to subdivision (r) of W&I Code § 14197.7.
J. Notification
The Department shall notify members benefiGiarioo of their Medi-Cal
specialty mental health benefits and options available upon termination or
expiration of this contract.
K. Performance Measurement
The Department shall measure the Contractor's performance based on
Medi-Cal approved claims and other data submitted by the Contractor to
the Department using standard measures established by the Department
in consultation with stakeholders.
County of Fresno
22-20101 Al
Page 12 of 17
Exhibit E
ADDITIONAL PROVISIONS
6. State and Federal Law Governing this Contract
A. The Contractor/Subrecipient Designation: the Contractor is considered a
contractor subject to 2 C.F.R Part 200 (45 C.F.R. Part 75).
B. The Contractor agrees to comply with all applicable federal and state law,
including but not limited to the statutes and regulations incorporated by
reference below in Sections D, G, and H, and applicable sections of the
State Plan, applicable federal waivers, and applicable Behavioral
Health Information Notices (BHINs) and waiver in its provision of
services as the Mental Health Plan. The Contractor agrees to comply with
any changes to these statutes, and regulations, State Plan, federal
waivers, and BHINs that n4ay occur during the contract period. The
Contractor shall also comply with a-PA any newer applicable statutes,- r
regulations, State Plan Amendments, federal waivers, and BHINs that
become effective during the contract period. These obligations shall
apply without the need for a Contract amendment(s). To the extent there
is a conflict between the terms of this Contract and any federal or state
taw statute or regulation the State Plan, federal waivers, or BHIN and a
r.r��ioc or�n on +hoc n�ntro nt the Contractor shall comply with the federal or
state law statute or regulation, the State Plan, federal waiver, or BHIN
and the conflicting Contract provision shall no longer be in effect.
C. The Contractor agrees to comply with all existing policy letters issued by
the Department. All policy letters issued by the Department subsequent to
the effective date of this Contract shall provide clarification of the
Contractor's obligations pursuant to this Contract, and may include
instructions to the Contractor regarding implementation of mandated
obligations pursuant to State or federal statutes or regulations, or pursuant
to judicial interpretation.
D. Federal Laws Governing this-Contract-
1 Title 42 United States Code, to the extent that these requirements
are applicable;
2) 42 C.F.R. to the extent that these requirements are applicable;
3) 42 C.F.R. Part 438, Medicaid Managed Care, limited to those
provisions that apply to Prepaid Inpatient Health Plans (PIHPs),
except for the provisions listed in paragraph D and E, below.
County of Fresno
22-20101 Al
Page 13 of 17
Exhibit E
ADDITIONAL PROVISIONS
4) 42 C.F.R. § 455 to the extent that these requirements are
applicable;
5) 45 C.F.R. § 92.1 et seq. to the extent these requirements are
applicable;
6) Title VI of the Civil Rights Act of 1964;
7) Title IX of the Education Amendments of 1972;
8) Age Discrimination Act of 1975;
9) Rehabilitation Act of 1973;
10) Americans with Disabilities Act;
11) Section 1557 of the Patient Protection and Affordable Care Act;
12) Deficit Reduction Act of 2005;
13) Balanced Budget Act of 1997;
14) The Contractor shall comply with the provisions of the Copeland
Anti-Kickback Act, which requires that all contracts and
subcontracts in excess of $2000 for construction or repair awarded
by the Contractor and its subcontractors shall include a provision
for compliance with the Copeland Anti-Kickback Act.
15) The Contractor shall comply with the provisions of the Davis-Bacon
Act, as amended, which provides that, when required by Federal
Medicaid program legislation, all construction contracts awarded by
the Contractor and its subcontractors of more than $2,000 shall
include a provision for compliance with the Davis-Bacon Act as
supplemented by Department of Labor regulations.
16) The Contractor shall comply with the provisions of the Contract
Work Hours and Safety Standards Act, as applicable, which
requires that all subcontracts awarded by the Contractor in excess
of $2,000 for construction and in excess of$2,500 for other
subcontracts that involve the employment of mechanics or laborers
shall include a provision for compliance with the Contract Work
Hours and Safety Standards Act.
County of Fresno
22-20101 Al
Page 14 of 17
Exhibit E
ADDITIONAL PROVISIONS
17) Any applicable federal and state laws that pertain to
memberb8RefiGiary rights.
18) Should any part of the scope of work under this contract relate to a
State program receiving Federal Financial Participation (FFP) that
is no longer authorized by law (e.g., which has been vacated by a
court of law, or for which CMS has withdrawn federal authority, or
which is the subject of a legislative repeal), the Contractor must do
no work on that part after the effective date of the loss of such
program authority. DHCS must adjust payments to remove costs
that are specific to any State program or activity receiving FFP that
is no longer authorized by law. If the Contractor works on a State
program or activity receiving FFP that is no longer authorized by
law after the date the legal authority for the work ends, the
Contractor will not be paid for that work. If DHCS has paid
Contractor in advance to work on a no-longer-authorized State
program or activity receiving FFP and under the terms of this
contract the work was to be performed after the date the legal
authority ended, the payment for that work should be returned to
DHCS. However, if the Contractor worked on a State program or
activity receiving FFP prior to the date legal authority ended for that
State program or activity, and DHCS included the cost of
performing that work in its payments to the Contractor, the
Contractor may keep the payment for that work even if the payment
was made after the date the State program or activity receiving FFP
lost legal authority. DHCS will attempt to provide Contractor with
timely notice of the loss of program authority.
E. The following sections of 42 Code of Federal Regulations, part 438 are
inapplicable to this Contract:
1) §438.3(b) Standard Contract Provisions — Entities eligible for
comprehensive risk contracts
2) §438.3(c) Standard Contract Provisions - Payment
3) §438.3(g) Standard Contract Provisions - Provider preventable
conditions
4) §438.3(o) Standard Contract Provisions - LTSS contract
requirements
County of Fresno
22-20101 Al
Page 15 of 17
Exhibit E
ADDITIONAL PROVISIONS
5) §438.3(p) Standard Contract Provisions — Special rules for HIOs
6) §438.3(s) Standard Contract Provisions — Requirements for MCOs,
PIHPs, or PAHPs that provide covered outpatient drugs
7) §438.4 Actuarial Soundness
8) §438.5 Rate Development Standards
9) §438.6 Special Contract Provisions Related to Payment
10) §438.7 Rate Certification Submission
11) §438.8 Medical Loss Ratio Standards
12) §438.9 Provisions that Apply to Non-emergency Medical
Transportation
13) §438.50 State Plan Requirements
14) §438.52 Choice of MCOs, PIHPs, PAHPs, PCCMs, and PCCM
entities
15) §438.56 Disenrollment: requirements and limitations
16) §438.70 Stakeholder engagement when LTSS is delivered through
a managed care program
17) 438.74 State Oversight of the Minimum MLR Requirements
18) §438.104 Marketing
19) §438.106 Liability for Payment
20) §438.108 Cost Sharing
21) §438.110 Member advisory committee
22) §438.114 Emergency and Post-Stabilization
23) §438.362 Exemption from External Quality Review
24) §438.700-730 Basis for Imposition of Sanctions
County of Fresno
22-20101 Al
Page 16 of 17
Exhibit E
ADDITIONAL PROVISIONS
25) §438.802 Basic Requirements
26) §438.810 Expenditures for Enrollment Broker Services
27) §438.816 Expenditures for the memberhe�iary support system
for enrollees using LTSS
F. Specific provisions of 42 Code of Federal Regulations, part 438 relating to
the following subjects are inapplicable to this Contract:
1) Long Terms Services and Supports
2) Managed Long Terms Services and Supports
3) Actuarially Sound Capitation Rates
4) Medical Loss Ratio
5) Religious or Moral Objections to Delivering Services
6) Family Planning Services
7) Drug Formularies and Covered Outpatient Drugs
G. Pursuant to W&I Code section 14704, a regulation or order concerning
Medi-Cal specialty mental health services adopted by the State
Department of Mental Health pursuant to Division 5 (commencing with
Section 5000), as in effect preceding the effective date of this section,
shall remain in effect and shall be fully enforceable, unless and until the
readoption, amendment, or repeal of the regulation or order by DHCS, or
until it expires by its own terms.
H. State Laws Governing this Contract:
The GentraGtGF shall GE)mnly with all State and federal statutes
regulatiORSe the terms of this Agreement, e
and any other appliGable
authorities In the event of a GenfliGt hofi m
between the terms of this Agreeent
anrrrd a-State orrfederal statute erregulation, or a BHINthe Gnntrar_--te_.rs;hi11
adhere to the ennlinable statute0 i reg nation or RHIN.
1) Division 5, W&I Code, to the extent that these requirements are
applicable to the services and functions set forth in this contract
2) W&I Code §§ 14059.5 and 14184.402
County of Fresno
22-20101 Al
Page 17 of 17
Exhibit E
ADDITIONAL PROVISIONS
3) W&I Code §§ 14680-14685.1
4) W&I Code §§ 14700-14727
5) Chapter 7, Part 3, Division 9, W&I Code, to the extent that these
requirements are applicable to the services and functions set forth
in this contract
6) Cal. Code Regs., tit. 9, § 1810.100 et. seq. — Medi-Cal Specialty
Mental Health Services, except for those regulations that are
superseded by BHINs
7) Cal. Code Regs., tit. 22, §§ 50951 and 50953
8) Cal. Code Regs., tit. 22, §§ 51014.1 and 51014.2
County of Fresno
22-20101 Al
Page 1 of 9
Exhibit E — Attachment 1
DEFINITIONS
1. The feNew+ng definitions and the definitions contained in Cal. Code Regs., tit. 9,
sections 1810.100-1850.535 shall apply in this Contract unless they are
superseded by BHIN. The following definitions shall also apply to this
Contract unless they are superseded by BHIN. If there is a conflict between
the following definitions and the definitions in Cal. Code Regs., tit. 9, sections
1810.100-1850.535, the following definitions below will apply. If there is a
conflict with the following definitions and BHIN, the BHIN shall apply.
A. "Advance Directives" means a written instruction, such as a living will or
durable power of attorney for health care, recognized under State law
(whether statutory or as recognized by the courts of the State), relating to
the provision of the healthcare when the individual is incapacitated.
B. "Abuse" means, as the term described in, provider practices that are
inconsistent with sound, fiscal, business, or medical practices, and result
in an unnecessary cost to the Medi-Cal program, or in reimbursement for
services that are not medically necessary or that fail to meet professionally
recognized standards for health care. It also includes memberhe�iary
practices that result in unnecessary cost to the Medi-Cal program. (See 42
C.F.R. §§ 438.2, 455.2)
C. "American Indian/Alaska Native (AI/AN)" —Any person defined in 25
United States Code sections 1603(13), 1603(28), or section 1679(a), or
who has been determined eligible as an Indian under 42 CFR section
136.12.
D. "Appeal" means a review by the Contractor of an adverse benefit
determination.
E. "Assessment" means a service activity designed to collect
information and evaluate the current status of a member's mental,
emotional, or behavioral health to determine whether Rehabilitative
Mental Health Services are medically necessary and to recommend
or update a course of treatment for that member. Assessments shall
be conducted and documented in accordance with applicable State
and Federal statutes, regulations, and standards. (State Plan,
Supplement 3 to Attachment 3.1-A, page 1 FTN 22-00231.)
F. "Membe[Be ary" means a Medi-Cal recipient who is currently
receiving services from the Contractor.
G. "Contractor" means County of Fresno.
County of Fresno
22-20101 Al
Page 2 of 9
Exhibit E — Attachment 1
DEFINITIONS
H. "Covered Specialty Mental Health Services" are defined in Exhibit E,
Attachment 2.
I. "Department" means the California Department of Health Care Services
(DHCS).
J. "Director" means the Director of DHCS.
K. "Discrimination Grievance" means a complaint concerning the unlawful
discrimination on the basis of any characteristic protected under federal or
state law, including sex, race, color, religion, ancestry, national origin,
ethnic group identification, age, mental disability, physical disability,
medical condition, genetic information, marital status, gender, gender
identity, or sexual orientation.
L. "Emergency" means a condition or situation in which an individual has a
need for immediate medical attention, or where the potential for such need
is perceived by emergency medical personnel or a public safety agency.
(Health & Safety Code § 1797.07)
M. "Fraud" means an intentional deception or misrepresentation made by a
person with the knowledge that the deception could result in some
unauthorized benefit to self or some other person. It includes an act that
constitutes fraud under applicable State and Federal law. (42 C.F.R. §§
438.2, 455.2)
N. "Grievance" means an expression of dissatisfaction about any matter
other than adverse benefit determination. Grievances may include, but are
not limited to, the quality of care or services provided, and aspects of
interpersonal relationships such as rudeness of a provider or employee, or
failure to respect the member'sbeRefiGiary'c rights regardless of whether
remedial action is requested. Grievance includes a member'sbeRefiGiary's
right to dispute an extension of time proposed by the Contractor to make
an authorization decision. (42 C.F.R. § 438.400)
O. "Habilitative services and devices" help a person keep, learn, or improve
skills and functioning for daily living. (45 C.F.R. § 156.115(a)(5)(i))
P. "HHS" means the United States Department of Health and Human Service
Q. "Homelessness" means The memberhe�iary meets the definition
established in section 11434a of the federal McKinney-Vento Homeless
County of Fresno
22-20101 Al
Page 3 of 9
Exhibit E — Attachment 1
DEFINITIONS
Assistance Act.15 Specifically, this includes (A) individuals who lack a
fixed, regular, and adequate nighttime residence (within the meaning of
section 103(a)(1) of the Act); and (B) includes (i) children and youths who
are sharing the housing of other persons due to loss of housing, economic
hardship, or a similar reason; are living in motels, hotels, trailer parks, or
camping grounds due to the lack of alternative adequate
accommodations; are living in emergency or transitional shelters; or are
abandoned in hospitals; (ii) children and youths who have a primary
nighttime residence that is a public or private place not designed for or
ordinarily used as a regular sleeping accommodation for human beings
(within the meaning of section 103(a)(2)(C)); (iii) children and youths who
are living in cars, parks, public spaces, abandoned buildings, substandard
housing, bus or train stations, or similar settings; and (iv) migratory
children (as such term is defined in section 1309 of the Elementary and
Secondary Education Act of 1965) who qualify as homeless for the
purposes of this subtitle because the children are living in circumstances
described in clauses (i) through (iii).
R. "Indian Health Care Provider (IHCP)" means a health care program
operated by the IHS ("IHS facility"), an Indian Tribe, a Tribal Organization,
or Urban Indian Organization (otherwise known as an I/T/U) as those
terms are defined in section 4 of the Indian Health Care Improvement Act
(25 U.S.C. § 1603).
S. "Indian Health Service (IHS) facilities" — Facilities and/or health care
programs administered and staffed bV the federal Indian Health
Service.
T. "Involvement in child welfare" means the membeI ben ary has an open
child welfare services case, or the membe is determined by a
child welfare services agency to be at imminent risk of entering foster care
but able to safely remain in their home or kinship placement with the
provision of services under a prevention plan, or the memberbenefiGiary is
a child whose adoption or guardianship occurred through the child welfare
system. A child has an open child welfare services case if: a) the child is in
foster care or in out of home care, including both court-ordered and by
voluntary agreement; or b) the child has a family maintenance case (pre-
placement or post-reunification), including both court-ordered and by
voluntary agreement. A child can have involvement in child welfare
whether the child remains in the home or is placed out of the home.
County of Fresno
22-20101 Al
Page 4 of 9
Exhibit E — Attachment 1
DEFINITIONS
U. "Juvenile justice involvement" means the membeEben ary (1) has ever
been detained or committed to a juvenile justice facility, or (2) is currently
under supervision by the juvenile delinquency court and/or a juvenile
probation agency. Members BenefiGiarioo who have ever been in custody
and held involuntarily through operation of law enforcement authorities in
a juvenile justice facility, including youth correctional institutions, juvenile
detention facilities, juvenile justice centers, and other settings such as
boot camps, ranches, and forestry/conservation camps, are included in
the "juvenile justice involvement" definition. Members BenefiGnarioo on
probation, who have been released home or detained/placed in foster care
pending or post-adjudication, under probation or court supervision,
participating in juvenile drug court or other diversion programs, and who
are otherwise under supervision by the juvenile delinquency court and/or a
juvenile probation agency also meet the "juvenile justice involvement"
criteria.
V. "Managed Care Organization" (MCO) means an entity that has, or is
seeking to qualify for, a comprehensive risk contract under 42 C.F.R. Part
438, and is: 1) a Federally qualified HMO that meets the advance
directives requirements of Subpart I of Part 489 of 42 C.F.R.; or, 2) any
public or private entity that meets the advance directive requirements and
is determined by the Secretary of Health and Human Services to also
meet the following conditions: i) makes the services that it provides to its
Medicaid members benefiGnari as accessible (in terms of timeliness,
amount, duration, and scope) as those services are to other Medicaid
members benefiGnari within the area served by the entity, ii) meet the
solvency standards of 42 C.F.R. 438.116. (42 C.F.R. § 438.2)
W. "Medically necessary" or "medical necessity" has the same meaning as
set forth in Welfare and Institutions Code section 14059.5. For individuals
21 years of age or older, a service is "medically necessary" or a "medical
necessity" when it is reasonable and necessary to protect life, to prevent
significant illness or significant disability, or to alleviate severe pain. For
individuals under 21 years of age, a service is "medically necessary" or a
"medical necessity" if the service meets the standards set forth in Section
1396d(r)(5) of Title 42 of the United States Code.
X. A "Network Provider" means any provider, group of providers, or entity
that has a network provider agreement with a Mental Health Plan, or a
subcontractor, and receives Medicaid funding directly or indirectly to order,
refer or render covered services as a result of the Department's contract
County of Fresno
22-20101 Al
Page 5 of 9
Exhibit E — Attachment 1
DEFINITIONS
with a Mental Health Plan. A network provider is not a subcontractor by
virtue of the network provider agreement. (42 C.F.R. § 438.2)
Y. "Out-of-network provider" means a provider or group of providers that
does not have a network provider agreement with a Mental Health Plan, or
with a subcontractor. (A provider may be "out of network" for one Mental
Health Plan, but in the network of another Mental Health Plan.)
Z. "Out-of-plan provider" has the same meaning as out-of-network provider.
AA. "Overpayment" means any payment made to a network provider by a
Mental Health Plan to which the network provider is not entitled under Title
XIX of the Act or any payment to a Mental Health Plan by a State to which
the Mental Health Plan is not entitled to under Title XIX of the Act. (42
C.F.R. § 438.2)
BB. "Peer Support Specialist" means an individual with a current State-
approved Medi-Cal Peer Support Specialist Certification Program
certification who meets ongoing education requirements and
provides services under the direction of a Behavioral Health
Professional. (State Plan, Supplement 3 to Attachment 3.1-A, page 2j
[TN 22-00231.)
CC. "Provider" means a person or entity who is licensed, certified, or otherwise
recognized or authorized under state law governing the healing arts to
provide specialty mental health services and who meets the standards for
participation in the Medi-Cal program as described in California Code of
Regulations, title 9, Division 1, Chapters 10 or 11 and in Division 3,
Subdivision 1 of Title 22, beginning with Section 50000. Provider includes
but is not limited to licensed mental health professionals, clinics, hospital
outpatient departments, certified day treatment facilities, certified
residential treatment facilities, skilled nursing facilities, psychiatric health
facilities, general acute care hospitals, and acute psychiatric hospitals.
The MHP is a provider when direct services are provided to members
benefiGaries by employees of the Mental Health Plan.
DD. "Physician Incentive Plans" mean any compensation arrangement to pay a
physician or physician group that may directly or indirectly have the effect
of reducing or limiting the services provided to any plan enrollee.
County of Fresno
22-20101 Al
Page 6 of 9
Exhibit E — Attachment 1
DEFINITIONS
EE. "PIHP" means Prepaid Inpatient Health Plan. A Prepaid Inpatient Health
Plan is an entity that:
1) Provides medical services to members b8R8fiGiaFi under contract
with the Department of Health Care Services, and on the basis of
prepaid capitation payments, or other payment arrangement that
does not use state plan rates;
2) Provides, arranges for, or otherwise has responsibility for the
provision of any inpatient hospital or institutional services for its
members beRefiGiari ; and
3) Does not have a comprehensive risk contract. (42 C.F.R. § 438.2)
FF. "Psychosocial Rehabilitation" means a recovery or resiliency
focused service activity which addresses a mental health need. This
service activity provides assistance in restoring, improving, and/or
preserving a member's functional, social, communication, or daily
living skills to enhance self-sufficiency or self-regulation in multiple
life domains relevant to the developmental age and needs of the
member. Psychosocial rehabilitation includes assisting members to
develop coping skills by using a group process to provide peer
interaction and feedback in developing problem-solving strategies.
In addition, psychosocial rehabilitation includes therapeutic
interventions that utilize self-expression such as art, recreation,
dance or music as a modality to develop or enhance skills. These
interventions assist the member in attaining or restoring skills which
enhance community functioning including problem solving,
organization of thoughts and materials, and verbalization of ideas
and feelings. Psychosocial rehabilitation also includes support
resources, and/or medication education. Psychosocial rehabilitation
may be provided to a member or a group of members. (State Plan,
Supplement 3 to Attachment 3.1-A, page 2a FTN 22-00231.)
GG. "Referral and Linkages" are services and supports to connect a
member with primary care, specialty medical care, substance use
disorder treatment providers, mental health providers, and
community-based services and supports. This includes identifying
appropriate resources, making appointments, and assistinq a
member with a warm handoff to obtain ongoing support. (State Plan,
Supplement 3 to Attachment 3.1-A, page 2b FTN 22-00231.)
County of Fresno
22-20101 Al
Page 7 of 9
Exhibit E — Attachment 1
DEFINITIONS
HH. "Significant Change" means when there is an increase or decrease in
the amount or types of services that are available, or if there is an
increase or decrease in the number of network providers, or if there
is any other change that would impact the benefits available through
this contract, or when there is a change in the scope of specialty
mental health services covered by this contract.
WhiGh addresses a MeRtal health Reed. This SeFViGe aGtiVity provides
assis+anne in resee rinr imnreiinn ender nreSE?FV'Rg a- henefi Gear\/'O
e e
fi in�enel Senia �emmi ini daily luting Skills +e enhanne Self
rarr vrrar�vc�rcrr�rrEa , rv-rr�nTrr�.r�vcn-rrcnTcc�c-rr
Si iffinienn.i er Self reg ilatien in multiple life rdemains relevant to +he
dGVelenmen+el erne and needs of the henefiniery C?ehabilitatinn else
innli ides Si invert reset irneS anther mediGatien ed ine+ien Rehabilitation
e
PRay he nreyided to a henefiniery or a nrei p of henefinierieS (Galifnrnie'S
MediGaid State Dien State DIen m en+ 10 016 /�ttaGme 3��
e /gy e e
S eMeRt3,p. 2a4
JJ. "Satellite site" means a site owned, leased or operated by an
organizational provider at which specialty mental health services are
delivered to members henefiniaries fewer than 20 hours per week, or, if
located at a multiagency site at which specialty mental health services are
delivered by no more than two employees or contractors of the provider.
KK. "Specialist" means a psychiatrist who has a license as a physician and
surgeon in this state and shows evidence of having completed the
required course of graduate psychiatric education as specified by the
American Board of Psychiatry and Neurology in a program of training
accredited by the Accreditation Council for Graduate Medical Education,
the American Medical Association, or the American Osteopathic
Association. (Cal. Code Regs., tit. 9 § 623.)
ILL. "Subcontract" means an agreement entered into by the Contractor with
any of the following:
1) Any other organization or person who agrees to perform any
administrative function or service for the Contractor specifically
related to securing or fulfilling the Contractor's obligations to the
Department under the terms of this contract.
County of Fresno
22-20101 Al
Page 8 of 9
Exhibit E — Attachment 1
DEFINITIONS
2) "Subcontractor" means an individual or entity that has a contract
with an MCO, PIHP, PAHP, or PCCM entity that relates directly or
indirectly to the performance of the MCO's, PIHP's, PAHP's, or
PCCM entity's obligations under its contract with the State. A
network provider is not a subcontractor by virtue of the network
provider agreement with the MCO, PIHP, or PAHP.
Notwithstanding the foregoing, for purposes of Exhibit D(F) the term
"subcontractor" shall include network providers.
MM. "Therapy" means a service activity that is a therapeutic intervention
that focuses primarily on symptom reduction and restoration of
functioning as a means to improve coping and adaptation and
reduce functional impairments. Therapeutic intervention includes the
application of cognitive, affective, verbal or nonverbal, strategies
based on the principles of development, wellness, adjustment to
impairment, recovery and resiliency to assist a member in acquiring
greater personal, interpersonal and community functioning or to
modify feelings, thought processes, conditions, attitudes or
behaviors which are emotionally, intellectually, or socially
ineffective. These interventions and techniques are specifically
implemented in the context of a professional clinical relationship.
Therapy may be delivered to a member or group of members and
may include family therapy directed at improving the member's
functioning and at which the member is present. (State Plan,
Supplement 3 to Attachment 3.1-A, page 2b FTN 22-00231.)
NN. "Treatment Planning" means s a service activity to develop or
update a member's course of treatment, documentation of the
recommended course of treatment, and monitoring a member's
progress. (State Plan, Supplement 3 to Attachment 3.1-A, page 2b
[TN 22-00231.)
00. "Tribal 638 Providers" — Federally recognized Tribes or Tribal
organizations that contractor or compact with IHS to plan, conduct
and administer one or more individual programs, functions, services
or activities under Public Law 93-638.
1) A Tribal 638 provider enrolled in Medi-Cal as an Indian Health
Services- Memorandum of Agreement (IHS-MOA) provider must
appear on the " List of American Indian Health Program Providers"
set forth in APL 17-020, Attachment1 in order to qualify for
County of Fresno
22-20101 Al
Page 9 of 9
Exhibit E — Attachment 1
DEFINITIONS
reimbursement as a Tribal 638 Provider under BHIN 22-020.
2) A Tribal 638 provider enrolled in Medi-Cal as a Tribal FQHC
provider is governed by and must enroll in Medi-Cal consistent
with the Tribal FQHC criteria established in the California State
Plan, 1 the Tribal FQHC section of the Medi-Cal provider manual,
and APL 21-008. Tribal 638 providers enrolled in Medi-Cal as a
Tribal FQHC must appear on the "List of Tribal Federally Qualified
Health Center Providers," which is set forth on Attachment 2 to
APL 21-008.
JJ. "Urban Indian Organizations (UIO)" — A Nonprofit corporate body
situated in an urban center, governed by an urban Indian controlled
board of directors, and providing for the maximum participation of all
interested Indian groups and individuals, which body is capable of
legally cooperating with other public and private entities for the
purpose of performing the activities described in section 1653(a) of
Title 25 of the Code of Federal Regulations.
County of Fresno
22-20101 Al
Page 1 of 11
Exhibit E — Attachment 2
SERVICE DEFINITIONS
1. The Contractor shall provide, or arrange and pay for, the following covered
specialty mental health services to members ber,efiniaries of Fresno County.
Services shall be provided as medically necessary and approved and authorized
according to State of California requirements. Services include:
A. "Mental Health Services" are individual, group, or family-based them
and interventions that are designed to provide a reduction of the
member's mental or emotional disability, aPA restoration, improvement
and/or preservation of individual and community functioning, and
continued ability to remain in the community malnteRanse gf
fi RGt consistent with the goals of recovery, resiliency, learning,
development, independent living, and enhanced self-sufficiency and that
are notThese serViGes are separate from these provided as components
of adult residential services, crisis residential services, crisis
intervention, crisis stabilization, day rehabilitation, or day treatment
intensive. Mental health services may include contact with significant
support persons or other collateral if the purpose of their
participation is to focus on the treatment of the member. This service
includes one or more of the following service components:
assessment, treatment planning, therapy, and psychosocial
rehabilitation. (State Plan, Supplement 3 to Attachment 3.1-A, page
2b FTN 22-00231.) SeFViGe aGtiVitieS may ORGlude but are not limited W:
1 Assee_sjmen� SerV!Ge aGtivity deSigRed to evaluate the GUrreRt
status of mental emotional or behavioral health
e �
�erapAsa�tGaaG that is a ranee itin irnteryention that
.-/ Therapy c''..--..'''' ``rrarrrc� ccrcrc-rrrccrvcTnwrT
font ices primarily OR symotem red Gtior) as a moons to red ine
fi�rGtienal impairrnents. Therapy any he delivered individual
or group anrd may innli de family therapy at whinh the client is
present.
3)R ilitation A service aGti ii t y t in ides but is not limited to
�vr�r�crvrc�ac � `7 rrrr �,�crc-rrrrvrnrrtrcccrc�
assmstaRGe imprnying maintainingi i or restoring fnGtional shills
0 0 0
d ;' - kills, social as leisure skills greemipg anrd persepal
hygiene skills; obtaining suppert reseugoes• arld/er obtaining
merdinatien erdi ination
l.
4) Collateral A sepyiGeaa �y nolVing a signmp�aaappo son
in the her,efiGiary's life for the purpose of addressing the mental
health eeds ef the benefiniary. CollateralInGlurde but is
limited tom, GeRSLA!tatiown arld rairaip f the s�i_gnifiQaarlt SaPP�et
persen(s) to assist in hotter utilization of mental health seFVines by
County of Fresno
22-20101 Al
Page 2 of 11
Exhibit E — Attachment 2
SERVICE DEFINITIONS
the Gliet_r�n� tio�dd training of the sinnifinGaantsupped
p n(s\ to assist in bettor i and ndino of mental illness and
pe�6i-r�--cv--avvr.�-c-rr-rrrccrcr-crrra �arm-rrc��arra
family Co�eli th- �Ga t support person/s\ The��ennt
rarrrrr� raw+ t^tg� l�P
may or may not he present for this seFVine antiVity.
B. "Medication Support Services" include prescribing, administering,
dispensing and monitoring of psychiatric medications or biologicals that
are necessary to alleviate the symptoms of mental illness. This service
aGti„ities may includes but are not limited to one or more of the
following service components: evaluation of the need for medication;
evaluation of clinical effectiveness and side effects; eb+ainiRg informed
mot; medication education including instruction in the use, risks
and benefits of, and alternatives for medication; treatment planning,
r•ollateral and plan development related to the delivery of serViGe and/er
assessment for the nlient• prescribing administering dispensing and
e f e
monitoring of psYnhiatrin medications or hieleginals• and mediGation
e
ed, n. Medication support services may include contact with
significant support persons or other collaterals if the purpose of
their participation is to focus on the treatment of the member. This
service may also include assessing the appropriateness of reducing
medication usage when clinically indicated. Medication support
services may be provided face-to-face, by telephone or by telehealth,
and may be provided anywhere in the community. Medication
support services may be delivered as a standalone service or as a
component of crisis stabilization.
C. "Day Treatment Intensive" is are a structured, multi-disciplinary program
of therapy that may be used as an alternative to hospitalization, or to avoid
placement in a more restrictive setting, or to maintain the client in a
community setting and which provides services to a distinct group of
members henefiniaries who receive services for a minima rn of at least
three hours per day (half-day) or mere than four hours per day (full-day),
and lasts less than 24 hours each day. Ser„ine aGti„ities may innli ode
but are not limited to This service includes one or more of the
following service components: assessment, plan develepment
treatment planning, therapy, and psychosocial rehabilitation-and
Gellateral. Cellateral addresses the RqeRtal health Reeds of the beRefiGiary
to ens ire Geerdinatien with signifinant others and treatment preyiders
This service may include contact with significant support persons or
other collaterals if the purpose of their participation is to focus on
the treatment of the member. Day treatment intensive services must
County of Fresno
22-20101 Al
Page 3 of 11
Exhibit E — Attachment 2
SERVICE DEFINITIONS
have a clearly established site for services although all services
need not be delivered at that site and some service components may
be delivered through telehealth or telephone. (State Plan,
Supplement 3 to Attachment 3.1-A, page 2c fTN 22-00231.)
D. "Day Rehabilitation" services are is a structured program which provides
services to a distinct group of individuals. Day rehabilitation is
intended to improve or restore personal independence and
functioning necessary to live in the community or prevent
deterioration of personal independence consistent with the
principles of learning and development. Services are available for at
least three hours each day. Day rehabilitation is a program that lasts
less than 24 hours each day. Day rehabilitation may include contact
with significant support persons or other collaterals if the purpose of
their participation
� ,is to focus on the treatment of the member�f
rehabil+ttatiOR ar}d therapy with serv+Gs-te i mairlta♦n er rescrnti
nnrsnnal inrdenenrdenne arl d fi inntinninn nnnsiconnt t i yith renirements fnr
e
learning arl d rdeyelenment arl d whiGh provides services to a rdistinot group
of berlefi^in�swho ,— icrvcNFViGec fnr a minima im of three he arc per day
(half day) or mere thani i fet hei irs per day (full day). Seryine antiyities may
rc ,de but are n�o This service includes one or more of the
following service components: assessment, plan rdeyeleprneRt treatment
planning, therapy, and psychosocial rehabilitation. (State Plan,
Supplement 3 to Attachment 3.1-A, page 2c fTN 22-00231.) and
rnllateral Collateral addresses the mental health needs of the henefiniary
c�zTrc-rrTcrrcuiTrccrrcrrrrcca�vrcrr�.
to ensi ire neerrdinatien with sienifinant others arl d treatment nreyii-ders
E. "Crisis Intervention" is an unplanned, expedited service last less than 24
hours and are for, to or on behalf of, a member fAr to address a condition
that requires more timely response than a regularly scheduled visit. Crisis
intervention is an emergency response service enabling a member to
cope with a crisis, while assisting the member in regaining their
status as a functioning community member. The goal of crisis
intervention is to stabilize an immediate crisis within a community or
clinical treatment setting. It may include contact with significant
support persons or other collaterals if the purpose of their
participation is to focus on the treatment of the member. SeFViGe
activities ORGli irde but are net limited to, This service includes one or
more of the following service components: assessment, Go'lateral anrd
therapy, and referral and linkages. Crisis Intervention services may
either be face-to-face or by telephone or telehealth with the henefiniaFy or
the henefiniary's sienifinant si invert nersen and may be provided in a
County of Fresno
22-20101 Al
Page 4 of 11
Exhibit E — Attachment 2
SERVICE DEFINITIONS
clinic setting or anywhere in the community. (State Plan, Supplement 3
to Attachment 3.1-A, page 2d FTN 22-00231.)
F. "Crisis Stabilization" is an unplanned, expedited service lasting less
than 24 hours ate, to or on behalf of, a memberhen ary fe-F to
address an urgent condition #iaf requiring immediate attention that
cannot be adequately or safely addressed in a community setting a
mere timely response than a regularly sGhedi lied visit. The goal of crisis
stabilization is to avoid the need for inpatient services which, if the
condition and symptoms are not treated, present an imminent threat
to the member or others, or substantially increase the risk of the
member becoming gravely disabled. Crisis stabilization must be
provided on site at a licensed 24-hour health care facility, at a
hospital based outpatient program (services in a hospital based
outpatient program are provided in accordance with 42 CFR 440.20),
or at a provider site certified by the Department of Health Care
Services to perform crisis stabilization and some service
components may be delivered through telehealth or telephone. Crisis
stabilization is an all-inclusive program and no other Rehabilitative
Mental Health Services are reimbursable during the same time period
this service is reimbursed. Crisis stabilization may include contact
with significant support persons or other collaterals if the purpose of
their participation is to focus on the treatment of the member.
Medical backup services must be available either on site or by
written contract or agreement with a general acute care hospital.
Medical backup means immediate access within reasonable
proximity to health care for medical emergencies. Medications must
be available on an as needed basis and the staffing pattern must
reflect this availability. All members receiving crisis stabilization
must receive an assessment of their physical and mental health. This
may be accomplished using protocols approved by a physician. If
outside services are needed, a referral that corresponds with the
member 's needs will be made, to the extent resources are available.
Ser„ine aGti„ities innli ide but are not limited to This service includes one
or more of the following service components: assessment, ^ellal,
and therapy, crisis intervention, medication support services, referral
and linkages. Collateral addresses the mental health needs of the
member henefiniary to ensure noordination with sinnifinant others and
treatment nre.,iders (State Plan, Supplement 3 to Attachment 3.1-A,
page 2e [TN 22-00231.)
G. "Adult Residential Treatment Services" are recovery focused
rehabilitative services provided in a non-institutional, residential setting for
County of Fresno
22-20101 Al
Page 5 of 11
Exhibit E — Attachment 2
SERVICE DEFINITIONS
members henefiniaries who would be at risk of hospitalization or other
institutional placement if they were not in the Teee+v+ig residential
treatment program seYvcrviGes. The service is available 24 hours a day,
seven days a week and structured day and evening services are
available all seven days. Adult residential treatment services must
have a clearly established site for services although all services
need not be delivered at that site and some service components may
be delivered through telehealth or telephone. The ser„Ones innli ilde a
wide range of antiyities and serViGes that support henefiGiaries in their
effort + steee m^in+^ine and apply in+ernercnn^I and iRdeneRden+ living
chills and to anness r•emmi inity si inner+ systems SerVine aGtivities may
e Services will not be claimable unless the member has been
admitted to the program and there is face-to-face contact between
the member and a treatment staff person of the facility on the day of
the service. This service includes one or more of the following
components: assessment, treatment planning plan deyelOpMerr+
therapy, and psychosocial rehabilitation, and GGllater^'. (State Plan,
Supplement 3 to Attachment 3.1-A, page 2f FTN 22-00231.) 4
addresses the mental health needs of the henefiGiary to ensure
neerdin^tien with sigRifinant others and treatment providers
H. "Crisis Residential Treatment Services" are therapeutic or rehabilitative
services provided in a non-institutional residential setting which
provides a structured program (short term-3 months or less) as an
alternative to hospitalization for members experiencing an acute
psychiatric episode or crisis who do not have medical complications
requiring nursing care. This service is available 24 hours a day,
seven days a week and structured day and evening services are
available all seven days. Crisis residential treatment services must
have a clearly established site for services although all services
need not be delivered at that site and some service components may
be delivered through telehealth or telephone. Services will not be
claimable unless the member has been admitted to the program and
there is face-to-face contact between the member and a treatment
staff person of the facility on the day of the service. an alternative to
Terri lire hesnital+zatieR. The GRS programs fer adults provide nermalize
liVino eRVirenments e n•r integrated irate residential neM inities This service
includes one or more of the following: fellew a serial rehabilitation
model that integrates asneGts of emergennY nsYnhiatr1G rare
e
assessment, treatment planning, therapy, psychosocial rehabilitation,
County of Fresno
22-20101 Al
Page 6 of 11
Exhibit E — Attachment 2
SERVICE DEFINITIONS
and crisis intervention. (State Plan, Supplement 3 to Attachment 3.1-
A, page 2g FTN 22-00231.) mike„ thorn., Base management and
pragtigal sogial we fk
I. "Psychiatric Health Facility Services" are therapeutic and/or
rehabilitative services provided in a psychiatric health facility
licensed by DHCS. Psychiatric health facilities are licensed to
provide acute inpatient psychiatric treatment to individuals with
major mental disorders. Psychiatric health facility services may
include contact with significant support persons or other collaterals
if the purpose of their participation is to focus on the treatment of the
member. Services are provided in a psychiatric health facility under a
multidisciplinary model and some service components may be
delivered through telehealth or telephone. Psychiatric health
facilities may only admit and treat patients who have no physical
illness or injury that would require treatment beyond what ordinarily
could be treated on an outpatient basis. Services include the
following components: assessment, treatment planning, therapy,
psychosocial rehabilitation, and crisis intervention. Ds"nhiatrin Health
Fa s a fa igensed ,,nd the nro"isions h with Se�on
i is Tccrr..rcazrrrae-�crr eg �rrrcrrvc vrr
77001 of Chapter Q, [Division F, Title 22 of the California Gode of
RegtlatiORS.. PSYGhiatFiG Health FaGiIi�ernvices" are theraineu in one and/evr
e
rehabilitative
barehabilitative�e Ser"ines provided in a nc"nhiatrin health fanility on an
0Rpat+ent basis beRef igiarias �n,hn need aGuto GaYr whi meets
� ch ms the
Criteria of SeEtlen 1820.205 of Chapter 11, on ,
[Division 1 Title Q�of tile
Galifernia Code of C?egulations and whose physical health needs nag he
,
met in an affiliated general ao,,te pare hospital or in outpatient settings
These services are separate from those categorized as "Psychiatric
Inpatient Hospital". (State Plan, Supplement 3 to Attachment 3.1-A,
page 2g FTN 22-00231.)
J. "Peer Support Services" are culturally competent individual and
group services that promote recovery, resiliency, engagement,
socialization, self-sufficiency, self-advocacy, development of natural
supports, and identification of strengths through structured
activities such as group and individual coaching to set recovery
goals and identify steps to reach the goals. Services aim to prevent
relapse, empower members through strength-based coaching,
support linkages to community resources, and to educate members
and their families about their conditions and the process of recovery.
Peer support services may be provided with the member or
significant support person(s) and may be provided in a clinical or
non-clinical setting. Peer support services can include contact with
County of Fresno
22-20101 Al
Page 7 of 11
Exhibit E — Attachment 2
SERVICE DEFINITIONS
family members or other collaterals if the purpose of the collateral's
participation is to focus on the treatment needs of the member by
supporting the achievement of the member's treatment goals.
Peer support services are based on an approved plan of care and
may be delivered as a standalone service. Peer support services
include one or more of the following service components:
1) Educational Skill Building Groups, which are groups
provided in a supportive environment in which members
and their families learn coping mechanisms and problem-
solving skills in order to help the members achieve desired
outcomes. These groups promote skill building for the
members in the areas of socialization, recovery, self-
sufficiency, self-advocacy, development of natural
supports, and maintenance of skills learned in other
support services.
2) Engagement, which means Peer Support Specialist led
activities and coaching to encourage and support members
to participate in behavioral health treatment. Engagement
may include supporting members in their transitions and
supporting members in developing their own recovery
goals and processes.
3) Therapeutic Activity, which means structured non-clinical
activity provided by a Peer Support Specialist to promote
recovery, wellness, self-advocacy, relationship
enhancement, development of natural supports, self-
awareness and values, and the maintenance of community
living skills to support the member's treatment to attain and
maintain recovery within their communities. These
activities may include, but are not limited to, advocacy on
behalf of the member; promotion of self-advocacy;
resource navigation; and collaboration with the members
and others providing care or support to the member, family
members, or significant support persons. (State Plan,
Supplement 3 to Attachment 3.1-A, page 2 FTN 22-00231.)
K. "Intensive Care Coordination (ICC)" is a targeted case management
service that facilitates assessment of care planning for and coordination of
services to members benefi^iaFioo under age 21 who are eligible for the
full scope of Medi-Cal services and who meet medical criteria to access
County of Fresno
22-20101 Al
Page 8 of 11
Exhibit E — Attachment 2
SERVICE DEFINITIONS
SMHS. ICC service components include: assessing; service planning and
implementation; monitoring and adapting; and transition. ICC services are
provided through the principles of the Integrated Core Practice Model
(ICPM), including the establishment of the Child and Family Team (CFT)
to ensure facilitation of a collaborative relationship among a child, their
family and involved child-serving systems. The CFT is comprised of— as
appropriate, both formal supports, such as the care coordinator, providers,
case managers from child-serving agencies, and natural supports, such as
family members, neighbors, friends, and clergy and all ancillary individuals
who work together to develop and implement the client plan and are
responsible for supporting the child and family in attaining their goals. ICC
also provides an ICC coordinator who:
1) Ensures that medically necessary services are accessed,
coordinated and delivered in a strength-based, individualized,
family/child driven and culturally and linguistically competent
manner and that services and supports are guided by the needs of
the child;
2) Facilitates a collaborative relationship among the child, their family
and systems involved in providing services to the child;
3) Supports the parent/caregiver in meeting their child's needs;
4) Helps establish the CFT and provides ongoing support; and
5) Organizes and matches care across providers and child serving
systems to allow the child to be served in their community.
L. "Intensive Home Based Services (IHBS)" are individualized, strength-
based interventions designed to ameliorate mental health conditions that
interfere with a child's functioning and are aimed at helping the child build
skills necessary for successful functioning in the home and community
and improving the child's family's ability to help the child successfully
function in the home and community. IHBS services are provided in
accordance with the Integrated Core Practice Model (ICPM) by the Child
and Family Team (CFT) in coordination with the family's overall service
plan which may include IHBS. Service activities may include, but are not
limited to assessment, treatment plan, therapy, rehabilitation and include
contact with significant support persons or other collaterals if the
purpose of their participation is to focus on the treatment of the
member G^"gal. IHBS is provided to members benefiGiari under 21
County of Fresno
22-20101 Al
Page 9 of 11
Exhibit E — Attachment 2
SERVICE DEFINITIONS
who are eligible for the full scope of Medi-Cal services and who meet the
access criteria for SMHS.
M. "Therapeutic Behavioral Services (TBS)" are intensive, individualized,
short-term outpatient treatment interventions for members benefiniarioc
up to age 21 . Individuals receiving these services have serious emotional
disturbances (SED), are experiencing a stressful transition or life crisis
and need additional short-term, specific support services.
N. "Therapeutic Foster Care (TFC) Services" model allows for the provision
of short-term, intensive, highly coordinated, trauma informed and
individualized specialty mental health services activities (plan
development, rehabilitation and collateral) to children up to age 21 who
have complex emotional and behavioral needs and who are placed with
trained, intensely supervised and supported TFC parents. The TFC parent
serves as a key participant in the therapeutic treatment process of the
child. The TFC parent will provide trauma informed interventions that are
medically necessary for the child. TFC is intended for children yeUth who
require intensive and frequent mental health support in a family
environment. The TFC service model allows for the provision of certain
specialty mental health services activities (plan development, rehabilitation
and collateral) available under the EPSDT benefit as a home-based
alternative to high level care in institutional settings such as group homes
and an alternative to Short Term Residential Therapeutic Programs
(STRTPs).
O. "Psychiatric Inpatient Hospital Services" include both acute psychiatric
inpatient hospital services and administrative day services. Acute
psychiatric inpatient hospital services are provided to members
beRefiG.aries for whom the level of care provided in a hospital is medically
necessary to diagnose or treat a covered mental illness. Administrative
day services are inpatient hospital services provided to members
benefiniaries who were admitted to the hospital for an acute psychiatric
inpatient hospital service and the member's beRefiniaryis stay at the
hospital must be continued beyond the member's benefiGiaryis. need for
acute psychiatric inpatient hospital services due to lack of residential
placement options at non-acute residential treatment facilities that meet
the needs of the member beRefiniary.
Psychiatric inpatient hospital services are provided by SD/MC hospitals
and FFS/MC hospitals. MHPs claim reimbursement for the cost of
psychiatric inpatient hospital services provided by SD/MC hospitals
through the SD/MC claiming system. FFS/MC hospitals claim
County of Fresno
22-20101 Al
Page 10 of 11
Exhibit E — Attachment 2
SERVICE DEFINITIONS
reimbursement for the cost of psychiatric inpatient hospital services
through the Fiscal Intermediary. MHPs are responsible for authorization
of psychiatric inpatient hospital services reimbursed through either billing
system. For SD/MC hospitals and FFS/MC hospitals, the daily rate
0nG ides the GGS} ^�needed--professional s Vies. The-FFS M v
hospital gaily rote does not include professional services, which are billed
separately from the SD/MC and FFS/MC inpatient hospital services via
the SD/MC claiming system.
P. "Targeted case management" is a service that assists a member
he^ ry in accessing needed medical, educational, social,
prevocational, vocational, rehabilitative, or other community services. The
service activities may include, but are not limited to, communication,
coordination and referral; monitoring service delivery to ensure member
he^ ry access to services and the service delivery system; monitoring
of the member's beRef;^;ar„'G progress, placement services, and plan
development. TCM services may be face-to-face or by telephone with the
client or significant support persons and may be provided anywhere in the
community. Additionally, services may be provided by any person
determined by the MHP to be qualified to provide the service, consistent
with the scope of practice and state law.
Q. "Community-Based Mobile Crisis Intervention Services (also referred
to as "Mobile Crisis Services")" are services that provide rapid
response, individual assessment and community-based stabilization
to Medi-Cal members who are experiencing a behavioral health
crisis. Mobile Crisis Services are designed to provide relief to
members experiencing a behavioral health crisis, including through
de-escalation and stabilization techniques; reduce the immediate
risk of danger and subsequent harm; and avoid unnecessary
emergency department care, psychiatric inpatient hospitalizations,
and law enforcement involvement. Mobile Crisis Services include
warm handoffs to appropriate settings and providers when the
member requires additional stabilization and/or treatment services;
coordination with and referrals to appropriate health, social and
other services and supports, as needed, and short-term follow-up
support to help ensure the crisis is resolved and the member is
connected to ongoing care. Mobile Crisis Services are directed
toward the member in crisis but may include contact with a family
member(s) or other significant support collateral(s) if the purpose of
the collateral's participation is to assist the member in addressing
their behavioral health crisis and restoring the member to the
highest possible functional level. Mobile crisis services are provided
County of Fresno
22-20101 Al
Page 11 of 11
Exhibit E — Attachment 2
SERVICE DEFINITIONS
by a multidisciplinary mobile crisis team at the location where the
member is experiencing the behavioral health crisis. Locations may
include, but are not limited to, the member's home, school, or
workplace, on the street, or where a member socializes. Mobile Crisis
Services claimed under this option cannot be provided in hospitals
or other facility settings. Mobile crisis services shall be available to
members experiencing behavioral health crises 24 hours a day, 7
days a week, and 365 days a year.
Contractor Certification Clauses
CCC 04/2017
CERTIFICATION
I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am
duly authorized to legally bind the prospective Contractor to the clause(s) listed
below. This certification is made under the laws of the State of California.
Contractor/Bidder Firm Name (Printed) Federal ID Number
County of Fresno
By (Authorized Signature)
Printed Name and Title of Person Signing
Date Executed Executed in the County of
Fresno
CONTRACTOR CERTIFICATION CLAUSES
1. STATEMENT OF COMPLIANCE: Contractor has, unless exempted, complied with the
nondiscrimination program requirements. (Gov. Code §12990 (a-f) and CCR, Title 2,
Section 11102) (Not applicable to public entities.)
2. DRUG-FREE WORKPLACE REQUIREMENTS: Contractor will comply with the
requirements of the Drug-Free Workplace Act of 1990 and will provide a drug-free
workplace by taking the following actions:
a. Publish a statement notifying employees that unlawful manufacture, distribution,
dispensation, possession or use of a controlled substance is prohibited and specifying
actions to be taken against employees for violations.
b. Establish a Drug-Free Awareness Program to inform employees about:
1) the dangers of drug abuse in the workplace;
2) the person's or organization's policy of maintaining a drug-free workplace;
3) any available counseling, rehabilitation and employee assistance programs; and,
4) penalties that may be imposed upon employees for drug abuse violations.
c. Every employee who works on the proposed Agreement will:
1) receive a copy of the company's drug-free workplace policy statement; and,
2) agree to abide by the terms of the company's statement as a condition of employment
on the Agreement.
Failure to comply with these requirements may result in suspension of payments under
the Agreement or termination of the Agreement or both and Contractor may be ineligible
for award of any future State agreements if the department determines that any of the
following has occurred: the Contractor has made false certification, or violated the
certification by failing to carry out the requirements as noted above. (Gov. Code §8350 et
seq.)
3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION: Contractor certifies that
no more than one (1) final unappealable finding of contempt of court by a Federal court
has been issued against Contractor within the immediately preceding two-year period
because of Contractor's failure to comply with an order of a Federal court, which orders
Contractor to comply with an order of the National Labor Relations Board. (Pub. Contract
Code §10296) (Not applicable to public entities.)
4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO BONO
REQUIREMENT: Contractor hereby certifies that Contractor will comply with the
requirements of Section 6072 of the Business and Professions Code, effective January 1,
2003.
Contractor agrees to make a good faith effort to provide a minimum number of hours of
pro bono legal services during each year of the contract equal to the lessor of 30
multiplied by the number of full time attorneys in the firm's offices in the State, with the
number of hours prorated on an actual day basis for any contract period of less than a full
year or 10% of its contract with the State.
Failure to make a good faith effort may be cause for non-renewal of a state contract for
legal services, and may be taken into account when determining the award of future
contracts with the State for legal services.
5. EXPATRIATE CORPORATIONS: Contractor hereby declares that it is not an
expatriate corporation or subsidiary of an expatriate corporation within the meaning of
Public Contract Code Section 10286 and 10286.1, and is eligible to contract with the
State of California.
6. SWEATFREE CODE OF CONDUCT:
a. All Contractors contracting for the procurement or laundering of apparel, garments or
corresponding accessories, or the procurement of equipment, materials, or supplies,
other than procurement related to a public works contract, declare under penalty of
perjury that no apparel, garments or corresponding accessories, equipment, materials, or
supplies furnished to the state pursuant to the contract have been laundered or produced
in whole or in part by sweatshop labor, forced labor, convict labor, indentured labor under
penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor,
or with the benefit of sweatshop labor, forced labor, convict labor, indentured labor under
penal sanction, abusive forms of child labor or exploitation of children in sweatshop labor.
The contractor further declares under penalty of perjury that they adhere to the Sweatfree
Code of Conduct as set forth on the California Department of Industrial Relations website
located at www.dir.ca.gov, and Public Contract Code Section 6108.
b. The contractor agrees to cooperate fully in providing reasonable access to the
contractor's records, documents, agents or employees, or premises if reasonably
required by authorized officials of the contracting agency, the Department of Industrial
Relations, or the Department of Justice to determine the contractor's compliance with the
requirements under paragraph (a).
7. DOMESTIC PARTNERS: For contracts of$100,000 or more, Contractor certifies that
Contractor is in compliance with Public Contract Code section 10295.3.
8. GENDER IDENTITY: For contracts of$100,000 or more, Contractor certifies that
Contractor is in compliance with Public Contract Code section 10295.35.
DOING BUSINESS WITH THE STATE OF CALIFORNIA
The following laws apply to persons or entities doing business with the State of California.
1. CONFLICT OF INTEREST: Contractor needs to be aware of the following provisions
regarding current or former state employees. If Contractor has any questions on the
status of any person rendering services or involved with the Agreement, the awarding
agency must be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
1). No officer or employee shall engage in any employment, activity or enterprise from
which the officer or employee receives compensation or has a financial interest and
which is sponsored or funded by any state agency, unless the employment, activity or
enterprise is required as a condition of regular state employment.
2). No officer or employee shall contract on his or her own behalf as an independent
contractor with any state agency to provide goods or services.
Former State Employees (Pub. Contract Code §10411):
1). For the two-year period from the date he or she left state employment, no former state
officer or employee may enter into a contract in which he or she engaged in any of the
negotiations, transactions, planning, arrangements or any part of the decision-making
process relevant to the contract while employed in any capacity by any state agency.
2). For the twelve-month period from the date he or she left state employment, no former
state officer or employee may enter into a contract with any state agency if he or she was
employed by that state agency in a policy-making position in the same general subject
area as the proposed contract within the 12-month period prior to his or her leaving state
service.
If Contractor violates any provisions of above paragraphs, such action by Contractor shall
render this Agreement void. (Pub. Contract Code §10420)
Members of boards and commissions are exempt from this section if they do not receive
payment other than payment of each meeting of the board or commission, payment for
preparatory time and payment for per diem. (Pub. Contract Code §10430 (e))
2. LABOR CODE/WORKERS' COMPENSATION: Contractor needs to be aware of the
provisions which require every employer to be insured against liability for Worker's
Compensation or to undertake self-insurance in accordance with the provisions, and
Contractor affirms to comply with such provisions before commencing the performance of
the work of this Agreement. (Labor Code Section 3700)
3. AMERICANS WITH DISABILITIES ACT: Contractor assures the State that it complies
with the Americans with Disabilities Act (ADA) of 1990, which prohibits discrimination on
the basis of disability, as well as all applicable regulations and guidelines issued pursuant
to the ADA. (42 U.S.C. 12101 et seq.)
4. CONTRACTOR NAME CHANGE: An amendment is required to change the
Contractor's name as listed on this Agreement. Upon receipt of legal documentation of
the name change the State will process the amendment. Payment of invoices presented
with a new name cannot be paid prior to approval of said amendment.
5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN CALIFORNIA:
a. When agreements are to be performed in the state by corporations, the contracting
agencies will be verifying that the contractor is currently qualified to do business in
California in order to ensure that all obligations due to the state are fulfilled.
b. "Doing business" is defined in R&TC Section 23101 as actively engaging in any
transaction for the purpose of financial or pecuniary gain or profit. Although there are
some statutory exceptions to taxation, rarely will a corporate contractor performing within
the state not be subject to the franchise tax.
c. Both domestic and foreign corporations (those incorporated outside of California) must
be in good standing in order to be qualified to do business in California. Agencies will
determine whether a corporation is in good standing by calling the Office of the Secretary
of State.
6. RESOLUTION: A county, city, district, or other local public body must provide the State
with a copy of a resolution, order, motion, or ordinance of the local governing body which
by law has authority to enter into an agreement, authorizing execution of the agreement.
7. AIR OR WATER POLLUTION VIOLATION: Under the State laws, the Contractor shall
not be: (1) in violation of any order or resolution not subject to review promulgated by the
State Air Resources Board or an air pollution control district; (2) subject to cease and
desist order not subject to review issued pursuant to Section 13301 of the Water Code for
violation of waste discharge requirements or discharge prohibitions; or (3) finally
determined to be in violation of provisions of federal law relating to air or water pollution.
8. PAYEE DATA RECORD FORM STD. 204: This form must be completed by all
contractors that are not another state agency or other governmental entity.
Accounting String
FUND/SUBCLASS: 0001/10000
ORG: 56309999
ACCOUNTS: 4383, 4402, 4404, 4408, 4412, 4428