HomeMy WebLinkAboutAgreement A-24-260 Amendment I to Master Agreement No. 23-290.pdf Agreement No. 24-260
1 AMENDMENT NO. 1 TO SERVICE AGREEMENT
2 This Amendment No. 1 to Service Agreement ("Amendment No. 1") is dated
3 June 4, 2024 and is between each Contractor listed in Exhibit A-1 titled "DMC
4 Outpatient Vendor List", (each a "Contractor" and collectively as "Contractors"), and the County
5 of Fresno, a political subdivision of the State of California ("County").
6 Recitals
7 A. County is authorized through its Intergovernmental Agreement with the California
8 Department of Health Care Services ("DHCS" or"State") to arrange for the provision of
9 mandated Outpatient Substance Use Disorder treatment services, also known as Drug Medi-Cal
10 (DMC) in Fresno County.
11 B. County is authorized to contract with privately operated agencies for the provision of
12 alcohol and other drug treatment services, pursuant to Title 9, Division 4 of the California Code
13 of Regulations and Division 10.5 (commencing with Section 11750) of the California Health and
14 Safety Code.
15 C. Contractors are certified by the State to provide services required by the County.
16 D. On June 20t", 2023, the County and the Contractors entered into DMC Outpatient
17 Master Agreement, which is County Agreement No. 23-290 ("Agreement"), for the provision of
18 mandated Outpatient Substance Use Disorder treatment services, also known as Drug Medi-Cal
19 (DMC) in Fresno County.
20 E. The County and Contractors now desire to amend various subsections of the Agreement
21 to update provider reporting requirements to align with California Advancing and Innovating
22 Medi-Cal (CaIAIM) initiatives and the new Electronic Health Records system; extend the term
23 for the Contingency Management pilot program; and add Contractor participation requirements
24 for State efforts to improve culturally responsive care delivery.
25 F. The County and Contractors now desire to revise various exhibits, including Exhibit E,
26 DMC-ODS Specific Requirements, to incorporate minor technical changes, delete outdated
27 language, add language to clarify the ASAM requirements for all levels of care and qualified
28 providers, and add new DHCS requirements including standardized ASAM assessment tools,
1
1 naloxone availability and person served bill of rights language; Exhibit B, DMC Outpatient
2 Scope of Work, to include clarifying language regarding medically necessary services and Peer
3 Support training requirements; Exhibit C to include the current Guiding Principles of Care
4 Delivery; and Exhibit J, SUD Outpatient Services Rates, to include flat fee rates previously
5 added to the fee schedule through a Department-issued letter dated October 20, 2023.
6 The parties therefore agree as follows:
7 1. All references in the Agreement to "Exhibit A" shall be deemed references to Exhibit A-1.
8 Exhibit A-1 is attached and incorporated by this reference.
9 2. All references in the Agreement to "Exhibit B" shall be deemed references to Exhibit B-1.
10 Exhibit B-I is attached and incorporated by this reference.
11 3. All references in the Agreement to "Exhibit C" shall be deemed references to Exhibit C-1.
12 Exhibit C-1 is attached and incorporated by this reference.
13 4. All references in the Agreement to "Exhibit F shall be deemed references to Exhibit E-1.
14 Exhibit E-I is attached and incorporated by this reference.
15 5. All references in the Agreement to "Exhibit H" shall be deemed references to Exhibit H-1.
16 Exhibit H-I is attached and incorporated by this reference.
17 6. All references in the Agreement to "Exhibit X shall be deemed references to Exhibit J-1.
18 Exhibit J-1 is attached and incorporated by this reference.
19 7. That a new Section 1.8.1 shall be added to the agreement, located on page 4, beginning
20 on line 6 as follows:
21 1.8.1 Alcohol and Other Drug Certification. County requires Contractors of SUD
22 outpatient treatment programs that offer treatment, recovery, detoxification, or medication for
23 addiction treatment (MAT) services to obtain the California DHCS Alcohol and Other Drug
24 (AOD) Program Certification prior to offering treatment services. In accordance with BHIN 23-
25 058, existing Contractors must submit an Initial Application for Certification by January 1, 2024
26 and obtain certification by January 1, 2025. Contractor shall maintain a current AOD
27 Certification during the term of this Agreement. County shall terminate a Contractor from this
28 Agreement immediately in the event any of the following occurs:
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1 A. Contractor fails to submit to the County a copy of the AOD Certification within
2 thirty (30) days after being approved by DHCS, or
3 B. Certification is not maintained throughout the Agreement term."
4 8. That Article 1, Section 1.22 of the Agreement located at page 10, beginning at line 24
5 through page 12, line 15, "Reports," is deleted in its entirety and replaced with the following:
6 1.22 Reports. Contractors shall submit all information and data required by County
7 and State in accordance with Exhibit H-1 — Provider Reporting Requirements, incorporated in
8 this Agreement and also available on the DBH webpage at:
9 https://www.fresnocountyca.gov/Departments/Behavioral-Health/Providers/Contract-Provider-
10 Resources/Substance-Use-Disorder-Provider . Reporting requirements may be revised
11 periodically to reflect changes to State-mandated reporting. Contractors that are not in
12 compliance with reporting deadlines are subject to payment withholding until reporting
13 compliance is achieved. Reporting requirements include, but are not limited to, the following:
14 (A) Drug and Alcohol Treatment Access Report (DATAR) in an electronic format
15 provided by the State and due no later than five (5) days after the preceding month;
16 (B) Ca1OMS Treatment— Submit Ca1OMS treatment admission, discharge, annual
17 update, and "provider activity report" record in an electronic format through County's EHR, and
18 on a schedule as determined by the County which complies with State requirements for data
19 content, data quality, reporting frequency, reporting deadlines, and report method and due no
20 later than five (5) days after the preceding month. All CalOMS admissions, discharges and
21 annual updates must be entered into the County's CalOMS system within twenty-four (24) hours
22 of occurrence;
23 (C)ASAM Level of Care (LOC) — Submit ASAM LOC data in a format determined by
24 DBH, on a schedule as determined by the County which complies with State requirements;
25 (D) DMC Outpatient Timeliness and/or DMC Opioid Timeliness— Contractor shall
26 enter access information into County's EHR at time of first contact with person served;
27 (E) Ineligible Person Screening Report— Format provided by County DBH and due
28 by the fifteenth (15th) day of each month to comply with State requirements;
3
1 (F) LogicManager Incident Reporting —As needed, when incidents occur and as
2 instructed in Exhibit I, Protocol for Completion of Incident Report.
3 (G)Monthly Status Report— Format provided by County DBH and due by the fifteen
4 (15th) day of each month;
5 (H)Wait list— Required by residential providers only and due by the fifteen (15th) day
6 of each month;
7 (1) Grievance Log — Due by the fifteen (151h) day of each month;
8 (J) Missed Appointments —Contractor shall maintain missed appointment
9 information until such time that DBH is able to collect that information in its Electronic Health
10 Record or other database;
11 (K) Cultural Competency Survey— Completed semi-annually in a format to be
12 determined by DBH;
13 (L) Americans with Disabilities (ADA)—Annually, upon request by County DBH,
14 Contractor shall complete an ADA Accessibility Certification and Self-Assessment, including
15 Implementation Plan, for each service location;
16 (M)Culturally and Linguistically Appropriate Services (CLAS) —Annually, upon
17 request by County DBH, Contractor shall complete an agency CLAS survey in a format
18 determined by County DBH and shall submit a CLAS Self-Assessment, including an
19 Implementation Plan;
20 (N) Network Adequacy Certification Tool (NACT)—Annually, upon request,
21 Contractor shall submit NACT data as requested by County DBH;
22 (0)DMC-ODS 274 Provider Network Data Reporting — Due monthly by the twenty-
23 fifth (25th) day of each month and in a format provided by County DBH. Additionally, Contractors
24 are required to participate in 274 workgroup meetings with potential corrective actions or
25 sanctions, including withholding payment, for non-compliance."
26 9. That Article 3, Section 3.2 of the Agreement located at page 21, beginning at line 1
27 through line 7, "Contingency Management Pilot," is deleted in its entirety and replaced with the
28 following:
4
1 "3.2 Contingency Management Pilot. The term of the Contingency Management pilot
2 under this Agreement shall be July 1, 2023 through December 31, 2026 for Contractors that opt
3 into participation. Following the pilot period, should DHCS exercise the option of adding
4 contingency management as a permanent DMC-eligible service then contingency management
5 services will be aligned with the term of this Agreement stated in section 3.1."
6 10. That a new Section 9.1.1 shall be added to the agreement, located on page 30 after line
7 3:
8 "9.1.1 Participation Requirements. The Contractor shall participate in the
9 State's efforts to promote the delivery of services in a culturally competent manner to all
10 persons served, including those with limited English proficiency and diverse cultural and ethnic
11 backgrounds, disabilities, and regardless of gender, sexual orientation or gender identity. (42
12 CFR §438.206(c)(2).)"
13 11. The Contractor represents and warrants to the County that:
14 a. The Contractor is duly authorized and empowered to sign and perform its obligations
15 under this Amendment.
16 b. The individual signing this Amendment on behalf of the Contractor is duly authorized
17 to do so and his or her signature on this Amendment legally binds the Contractor to
18 the terms of this Amendment.
19 12. The parties agree that this Amendment may be executed by electronic signature as
20 provided in this section.
21 a. An "electronic signature" means any symbol or process intended by an individual
22 signing this Amendment to represent their signature, including but not limited to (1) a
23 digital signature; (2) a faxed version of an original handwritten signature; or (3) an
24 electronically scanned and transmitted (for example by PDF document) version of an
25 original handwritten signature.
26 b. Each electronic signature affixed or attached to this Amendment (1) is deemed
27 equivalent to a valid original handwritten signature of the person signing this
28 Amendment for all purposes, including but not limited to evidentiary proof in any
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1 administrative or judicial proceeding, and (2) has the same force and effect as the
2 valid original handwritten signature of that person.
3 c. The provisions of this section satisfy the requirements of Civil Code section 1633.5,
4 subdivision (b), in the Uniform Electronic Transaction Act (Civil Code, Division 3, Part
5 2, Title 2.5, beginning with section 1633.1).
6 d. Each party using a digital signature represents that it has undertaken and satisfied
7 the requirements of Government Code section 16.5, subdivision (a), paragraphs (1)
8 through (5), and agrees that each other party may rely upon that representation.
9 e. This Amendment is not conditioned upon the parties conducting the transactions
10 under it by electronic means and either party may sign this Amendment with an
11 original handwritten signature.
12 13. This Amendment may be signed in counterparts, each of which is an original, and all of
13 which together constitute this Amendment.
14 14. The Agreement as amended by this Amendment No. 1 is ratified and continued. All
15 provisions of the Agreement and not amended by this Amendment No. 1 remain in full force and
16 effect.
17 [SIGNATURE PAGE FOLLOWS]
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1 The parties are signing this Amendment No. 1 on the date stated in the introductory
2 clause.
3
CONTRACTOR COUNTY OFFRESNO
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SEE FOLLOWING SIGNATURE PAGES _
6 Nathan Magsig, Chairman of the Board of
Supervisors of the County of Fresno
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Attest:
8 Bernice E. Seidel
Clerk of the Board of Supervisors
9 County of Fresno, State of California
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By:
11 Deputy
12 For accounting use only:
13 Org No.: 56302081
Account No.: 7295/0
14 Fund No.: 0001
Subclass No.: 10000
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Provider: CENTRAL CALIFORNIA RECOVERY, INC.
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By
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5 Print Name: t;J
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Title:
Ch irman o e Boar , President, or Vice President
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9 Date: °^ 3Z2-
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Print Name: ��f4- AzA A
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15 Title:
16 Secretary (of Corporation), Assistant Secretary,
Chief Financial Officer, or Assistant Treasurer
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Provider: DELTA CARE, INC.
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gy
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5 Print Name:_P—1 T f t L j u c`1 vZ A-
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7 Title:Ev ;C�t t f 1 v i Op,
Chairman of the Board, President, or Vice President
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9 Date:
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12 By
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Print Name:;7 - 4
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� � e
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Title:
16 Secretary (of Corporation), Assistant Secre ary,
Chief Financial Officer, or Assistant Treasurer
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18 Date:
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The parties are executing this Amendment No. 1 to Agreement No. 23-290 on the date
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stated in the introductory clause.
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4 Provider: FRESNO NEW CONNECTION, INC.
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i4l-v
By
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Print Name: �u'�7�"��►h%1- bT1���- " i.�z.
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10 Title: to(qc
Chairman of the Board, President, or Vice President
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12 Date:
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15 By l 7
16 (� l
Print Name:
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18 Title:
of Corporation), Assistant Secretary,
19 Secretary �
Chief Financial Officer, or Assistant Treasurer
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DocuSign Envelope ID:6703DB8E-4019-4E37-B7C8-8B83A599A278
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Provider: KINGS VIEW
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FDocuSigned by:
By
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5 Amanda Nugent
Print Name: Divine, PhD
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CEO
7 Title:
Chairman of the Board, President, or Vice President
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9 Date: 5/2/2024
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11 DocuSigned by:
'<
12 BY
13 Michael
Print Name: Kosareff
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15 CFO
Title:
16 Secretary (of Corporation), Assistant Secretary,
Chief Financial Officer, or Assistant Treasurer
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18 Date: 5/2/2024
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Provider: MENTAL HEALTH SYSTEMS, INC.
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3 ^7AWS C CallaGrah 12
By
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5 Print Name: Ames C Callaghan Jr
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7 Title: CEO/President
Chairman of the Board, President, or Vice President
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9 Date: 05/01/24
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11
_paw Tau
12 BY
13 Print Name: David Tanner
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15 Title: VP of Corporate Finance
16 Secretary (of Corporation), Assistant Secretary,
Chief Financial Officer, or Assistant Treasurer
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05101/24
18 Date:
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Provider: PRODIGY HEALTHCARE INC.
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Chairman of t-ie Board, President, or Vice President
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16 Secretary (of Corporation), Assistant Secretary,
Chief Financia Officer, or Assistant Treasurer
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1 PROVIDER (GROUP): Promesa Behavioral Health
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3 By:
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5 Print Name: Michael Der Manouel
6 President
7 Title: _
Chairman of the Board, or
8 President, or any Vice President
9 04/29/24
10 Date: _
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13 By: —
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Print Name: Erlan Zuniga
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Title: F
17 Secretary (of Corporation), or
any Assistant Secretary, or
18 Chief Financial Officer, or
19 any Assistant Treasurer
20 Date: 04/29/24
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER (INDIVIDUAL): Promesa Behavioral Health
3 B
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5 Print Name: Lisa Welgant
6 C
7 Title: C C O
8 4/29/24
9 Date:
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COUNTY OF FRESNO
Fresno, CA
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The parties are executing this Amendment No. 1 to Agreement No. 23-290 on the date
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stated in the introductory clause.
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4 Provider: TURNING POINT OF CENTRAL CALIFORNIA, INC.
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6 By_
��an �a'hlcs
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8 Print Name: Ryan Banks
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10 Title: Chief Executive Officer
Chairman of the Board, President, or Vice President
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12 Date: 5/10/24
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15 By /�,.�...��i
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Print Name: Bruce Tyler
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18 Title: Interim Chief Financial Officer
19 Secretary (of Corporation), Assistant Secretary,
Chief Financial Officer, or Assistant Treasurer
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21 Date: 5/10/24
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Document ID:lbd b52e68le44d6a3b9b30f475d043c50e6le919baecbc627al962208487cb
Page 1
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Provider: WESTCARE CALIFORNIA, INC.
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3 ,
By_
4 \\
5 Print Name.��(�,,�fl �1d_v��C►v1 S
6
7 Title:
Chairman of the Board, President, or Vice President
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5/2/24
9 Date: _
px
11 C.t-�cTv wr.�n 1-k_j-,vvi WrC/_� ogoZ -01
12 By_ 'l
- fiUCFCw C�
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Print ame;,_�,r-t k1/-"t'j k)AX
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15 Title:_ec-C"Q 3
16 Secretary (of Corporation), AssistAnt Secretary,
Chief Financial Officer, or Assistant Treasurer
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18 Date:
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Fresno County Department of Behavioral Health Exhibit A-1
DMC Outpatient Vendor List
VENDOR CONTACT PHONE NUMBER/FAX EMAIL TYPE OF BUSINESS
Central California Recovery,Inc. President (559)273-2942 assessment_training_research@yahoo.com 501(c)3 Non-Profit Corporation
Remit to: (559)681-1947
1204 W.Shaw Ave.N302
Fresno,CA 93711
Delta Care,Inc. Executive Director (559)276-7558 deltacareinc@yahoo.com 501(c)3 Non-Profit Corporation
Remit to:
4705 N.Sonora Ave 8113
Fresno,CA 93706
Fresno New Connection,Inc. Executive Director (559)248-1548 sud@teamfnc.com 501(c)3 Non-profit Corporation
Remit to:
4411 N.Cedar Ave.0108
Fresno,CA 93726
Kings View CEO (559)2560100 MaRodriguez@kingsview.org 501(c)3 Non-profit Corporation
Remit to:
1396 W.Herndon Ave.
Fresno,CA 93711
Mental Health Systems,Inc. CEO (858)573-2600 contact@turnbhs.org 501(c)3 Non-profit Corporation
Remit to: CFO
9465 Farnham St.
San Diego,CA 92123
Prodigy Healthcare Inc. President (559)892-9452 jd@prodigy-hc.com 501(c)3 Non-profit Corporation
Remit to:
P.O.Box 820
Fowler,Ca 93625
Promesa Behavioral Health President (559)439-5437 mnajera@pmmesabehavioml.org 501(c)3 Non-profit Corporation
Remit to: Fax:(559)439-5411
7120 N.Marks Ave,N310
Fresno,Ca 93711
Turning Point of Central California,Inc. Chief Executive Officer (559)732-8086 info@tpocc.org 501(c)3 Non-profit Corporation
Remit to:
PO Box 7447
Visalia,CA 93290
WestCare California,Inc. Chief Operating Officer (559)251-4800 infoca@westcare.com 501(c)3 Non-profit Corporation
Remit to: Fax:(559)453-7827
1900 N.Gateway Blvd
Fresno,CA 93727
**A list of current provider sites can be found at:
https://w .co.fresno.ca.us/departments/behavioral-health/substance-use-disorder-services
6/04/2024 1 of 1
Exhibit B-1
1 Drug Medi-Cal
2 Outpatient Treatment
3 Scope of Work
4 Contractors, as listed in the Exhibit A-1, DMC Outpatient Vendor List, to this Master
5 Agreement shall provide administrative and direct program services to County's Medi-Cal
6 persons served as defined in Title 9, Division 1, Chapter 11 of the California Code of
7 Regulations. For persons served under the age of 21, the Contractor shall provide all medically
8 necessary SUD services required pursuant to Section 1396d(r)(r) of Title 42 of the United States
9 Code (Welfare & Institutions Code 14184.402(e)).
10 Contractors shall deliver services using evidence-based practice models. Contractors
11 shall provide said services in Contractor's program(s) as described herein; as permitted under
12 their respective DMC certifications; and utilizing locations as described herein.
13
14 TARGET POPULATION
15 Contractors shall provide services to the Medi-Cal population, who are residents of
16 Fresno County, including perinatal in accordance with the program's approved DMC
17 certification.
18
19 SERVICES TO BE PROVIDED
20 Contractors shall provide medically necessary covered Outpatient SUD services, as
21 defined in the Drug Medi-Cal (DMC) Billing Manual available in the DHCS County Claims
22 Customer Services Library page at: https://www.dhcs.ca.gov/services/MH/Pages/MedCCC-
23 Library.aspx, or subsequent updates to this billing manual, to clients who meet access criteria
24 for receiving SUD services.
25 Services shall be furnished in an amount, duration, and scope that is no less than the
26 amount, duration, and scope for the same services furnished to persons served under fee-for-
27 service Medicaid, as set forth in 42 CFR 440.230. Contractors shall ensure that the services are
28 sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for
B-1
Exhibit B-1
1 which the services are furnished. Contractors may not arbitrarily deny or reduce the amount
2 duration, or scope of a required service solely because of diagnosis, type of illness, or condition
3 of the person served.
4 In all levels of care, contractors are required to either offer medications for addiction
5 treatment (MAT) directly or demonstrate effective referral and linkage mechanisms in place to
6 the most clinically appropriate MAT services. Providing a person served the contact information
7 for a MAT program is insufficient.
8 Contractor shall not deny access to medically necessary services, including all FDA-
9 approved medications for OUD if a person served meets the medical necessity for DMC-ODS
10 services. Persons served shall not be put on a wait list to access medically necessary services.
11 Placement in an appropriate level of care must be determined through an assessment
12 based on the American Society of Addiction Medicine (ASAM) criteria and prescribed by the
13 contractor's medical director or through a brief screening based on ASAM criteria for youth
14 under age 21.
15 Contractor shall observe and comply with all lockout and non-reimbursable service rules,
16 as outlined in the Drug Medi-Cal Billing Manual.
17 EARLY INTERVENTION SERVICES (ASAM LEVEL 0.5)
18 Early intervention services (EIS) are available to persons served under 21 who are
19 screened and determined to be at risk of developing an SUD. At risk persons served may
20 receive any service component covered under the outpatient level of care (ASAM 1.0) as early
21 intervention services. An SUD diagnosis is not required for EIS.
22 A full assessment utilizing the ASAM criteria is not required for a person served under
23 the age of 21 to receive EIS. An abbreviated ASAM screening tool may be used. If the person
24 served under 21 meets diagnostic criteria for SUD, a full ASAM assessment shall be performed
25 and the person served shall receive a referral to the appropriate level of care indicated by the
26 assessment.
27 EIS services may be delivered in a wide variety of settings and can be provided in
28 person, by telehealth, or by telephone.
B-2
Exhibit B-I
1 EIS services do not limit or modify the Early Periodic Screening, Diagnostic and
2 Treatment (EPSDT) mandate.
3
4
5 OUTPATIENT SERVICES (ASAM LEVEL 1.0)
6 Outpatient services consist of up to nine (9) hours per week of medically necessary
7 services for adults and up to six (6) hours per week of services for adolescents. Services may
8 exceed the maximum hours based on individual medical necessity.
9 Services can be provided by a Licensed Practitioner of the Healing Arts (LPHA) or
10 registered/certified counselor in-person, by telephone, or telehealth in any appropriate setting in
11 the community, in conformance with HIPAA and 42 CFR Part 2. Group size is limited to no less
12 than two (2) and no more than twelve (12) persons served. Outpatient services may be provided
13 in person, by telehealth or by telephone.
14
15 Outpatient services include the following service components:
16 . Assessment
17 • Care Coordination
• Counseling (individual/group)
18 • Family Therapy
• Medication Services
19 • MAT for opioid use disorders
20 • MAT for alcohol use disorders and non-opioid SUDs
• Patient Education
21 • Recovery Services
• SUD Crisis Intervention Services
22
23 INTENSIVE OUTPATIENT SERVICES (ASAM LEVEL 2.1)
24 Intensive outpatient involves structured programming provided to persons served as
25 medically necessary for a minimum of nine (9) hours and a maximum of nineteen (19) hours for
26 adults and a minimum of six (6) hours and a maximum of nineteen (19)for adolescents.
27 Providers may exceed maximum treatment hours when determined to be medically necessary.
28
B-3
Exhibit B-I
1 Intensive outpatient treatment services include the same service components listed
2 under Outpatient 1.0.
3 Services can be provided by an LPHA or registered/certified counselor in-person, by
4 telephone, or telehealth in any appropriate setting in the community, in conformance with HIPAA
5 and 42 CFR Part 2. Group size is limited to no less than two (2) and no more than twelve (12)
6 persons served.
7 WITHDRAWAL MANAGEMENT (Level 1-WM, Level 2-WM and Level 3.2-WM)
8 Withdrawal management services are provided to persons served experiencing
9 withdrawal in the following outpatient, residential, or inpatient settings:
10 . Level 1 -WM: Ambulatory withdrawal management without extended on-site
11 monitoring (Mild withdrawal with daily or less than daily outpatient supervision).
Level 2-WM: Ambulatory withdrawal management with extended on-site
12 monitoring (Moderate withdrawal with daytime withdrawal management and
support and supervision in a non-residential setting).
13 • Level 3.2-WM: Clinically managed residential withdrawal management (24-hour
support for moderate withdrawal symptoms that are not manageable in outpatient
14 setting).
15 • Level 3.7-WM: Medically Managed Inpatient Withdrawal Management (24-hour
care for severe withdrawal symptoms requiring 24-hour nursing care and
16 physician visits).
• Level 4-WM: Medically managed intensive inpatient withdrawal management
17 (Severe, unstable withdrawal requiring 24-hour nursing care and daily physician
visits to modify withdrawal management regimen and manage medical
18 instability).
19
20 Withdrawal management (WM) services are prescribed based the ASAM criteria.
21 Contractor shall ensure persons served receiving both residential and outpatient WM services
22 are monitored during the detoxification process. Withdrawal Management services may be
23 provided in an outpatient or residential setting.
24 Withdrawal Management services are urgent and provided on a short-term basis. When
25 provided as part of withdrawal management services, service activities such as the assessment
26 shall focus on the stabilization and management of psychological and physiological symptoms
27 associated with withdrawal, engagement in care and effective transitions to a level of care
28 where comprehensive treatment services are provided.
B-4
Exhibit B-1
1 A full ASAM assessment shall not be required as a condition of admission to a
2 withdrawal management program.
3 ASAM 3.7-WM and 4-WM services are part of the DMC-ODS continuum of care but are
4 offered through the Medi-Cal Managed Care Plans, Anthem Blue Cross and CalViva Health. If
5 a person served is determined to need this level of care, the provider should provide a linkage
6 to the Managed Care Plans for treatment.
7
8 Withdrawal Management services include the following service components:
9 • Assessment
• Care Coordination
10 . Medication Services
11 MAT for opioid use disorders
• MAT for alcohol use disorders and non-opioid SUDs
12 • Observation
• Recovery Services
13
14 MEDICATION ASSISTED TREATMENT (MAT)
15 Medication for addiction treatment includes all FDA-approved medications and biological
16 products to treat Alcohol Use Disorders (AUD), Opioid Use Disorders (OUD) and any SUD.
17 MAT may be provided in clinical or non-clinical settings and can be delivered as a standalone
18 service or as a service delivered as part of another level of care.
19 Additional MAT involves the ordering, prescribing, administering, and monitoring of
20 medications for substance use disorders.
21 All DMC-ODS providers, at all levels of care, must demonstrate that they either directly
22 offer or have an effective referral and linkage mechanism/process to MAT for persons served
23 with SUD diagnoses. Providers shall monitor the referral and linkage process or the provision of
24 MAT services.
25 Persons served needing or utilizing MAT shall be served in all levels of care and cannot
26 be denied treatment services or be required to decrease dosage or be tapered off medications
27 as a condition of entering or remaining in the program. Persons served who decline counseling
28 services shall not be denied access to MAT or administratively discharged.
B-5
Exhibit B-1
1
2 MAT services may be provided in conjunction with the following service components:
3 . Assessment
• Care Coordination
4 • Counseling (individual/group)
5 • Family Therapy
• Medication Services
6 • Prescribing, administering, dispensing, ordering, monitoring and/or managing the
medications for MAT for opioid use disorders, alcohol use disorders and non-
7 opioid SUDs
8 • Patient Education
Recovery Services
g • SUD Crisis Intervention Services
• Withdrawal Management Services
10
11 CONTINGENCY MANAGEMENT (RECOVERY INCENTIVES)
12 Contingency Management (CM) is an evidence-based behavioral treatment that
13 provides motivational incentive to reduce the use of stimulants. CM is the only treatment that
14 has demonstrated robust outcomes for persons served with stimulant use disorder, including
15 reduction or cessation of drug use and longer retention in treatment.
16 CM is a structured 24-week program, followed by six or more months of additional
17 recovery support services. Persons served will be able to earn motivational incentives in the
18 form of low-denomination gift cards, with a total retail value determined per treatment episode.
19 Beginning in the Spring of 2023, CM will be piloted in select DMC-ODS counties,
20 including Fresno County, as an optional DMC benefit. CM will initially be available through DMC
21 certified outpatient providers that opted into participation during the pilot. Following the
22 conclusion of the CM pilot on December 31, 2026, opting in will become available to all
23 outpatient programs so long as DHCS adds CM as a permanent Medi-Cal benefit.
24 PEER SUPPORT SERVICES
25 Contractors that employ Medi-Cal Peer Support Specialists and have a designated Peer
26 Support Supervisor can begin to offer Peer Support Services upon County approval. Medi-Cal
27 Peer Support Specialists must have completed the Peer Support Specialist Training Program
28
B-6
Exhibit B-1
1 and receive their certification and designated supervisors must have completed the supervisor
2 training prior to billing for peer support services.
3 Peer support services promote recovery, resiliency, engagement, socialization, self-sufficiency,
4 self-advocacy, development of natural supports, and identification of strengths through
5 structured activities such as group and individual coaching to set recovery goals and identify
6 steps to reach the goals.
7 Peer support services may be provided with the person served or significant support
8 person(s) and may be provided in a clinical or non-clinical setting. Peer support services can
9 include contact with family members or other people (collaterals) supporting the person served if
10 the purpose of the collateral's participation is to focus on the treatment needs of the person
11 served.
12 Peer support services are delivered and claimed as a standalone service. Peer support
13 services can be provided in conjunction with other services or levels of care, including inpatient
14 and residential services, but shall be billed separately. There may be times when, based on
15 clinical judgment, the person served is not present during the delivery of the service, but
16 remains the focus of the service.
17 Peer Support Services are based on a plan of care that includes specific individualized
18 goals and is approved by a Behavioral Health Specialist or a Peer Support Supervisor.
19 Peer support services consist of Education Skill Building Groups, Engagement services
20 and Therapeutic Activity services.
21 Peer Support Specialists are individuals in recovery with a current State-approved Medi-
22 Cal Peer Support Specialist Certification Program certification and working under the direction
23 of a Behavioral Health Professional. Behavioral Health Professionals must be licensed,
24 waivered, or registered in accordance with applicable State of California licensure requirements
25 and listed in the California Medicaid State Plan as a qualified DMC provider.
26
27 RECOVERY SERVICES
28
B-7
Exhibit B-I
1 Recovery Services are designed to support recovery and prevent relapse with the
2 objective of restoring the person served to their best possible functional level.
3 Recovery services can be utilized when the person served is triggered, when the person
4 served has relapsed or simply as a measure to prevent relapse.
5 Persons served do not need to be diagnosed as being in remission to access Recovery
6 Services. Persons served may receive Recovery Services while receiving MAT services,
7 including NTP services. Persons served may receive Recovery Services immediately after
8 incarceration with a prior diagnosis of SUD. Services may be provided in person, by telehealth,
9 or by telephone. Recovery Services can be delivered and claimed as a standalone service,
10 concurrently with the other levels of care or as a service delivered as part of other levels of care.
11 Contractors that do not opt to make recovery services available must refer and provide
12 linkage to persons served to a contractor that provides recovery services.
13
14 Recovery Services shall include the following service components:
15 . Assessment
• Care Coordination
16 . Counseling (individual and group)
17 • Family Therapy
• Recovery Monitoring, which includes recovery coaching and monitoring designed
18 for the maximum reduction of the person served's SUD
• Relapse Prevention which includes interventions designed to teach persons
19 served with SUD how to anticipate and cope with the potential for relapse for the
20 maximum reduction of the person served's SUD.
21 CLINICIAN CONSULTATION
22 Clinician Consultation consists of LPHAs consulting with LPHAs, such as addiction
23 medicine physicians, addiction psychiatrists, licensed clinicians, or clinical pharmacists, to
24 support the provision of care.
25 Clinician Consultation is not a direct service provided to persons served. Clinician
26 Consultation is designed to support licensed clinicians with complex cases and may address
27 medication selection, dosing, side effect management, adherence, drug-drug interactions, or
28 level of care considerations. It includes consultations between clinicians designed to assist
B-8
Exhibit B-I
1 clinicians with seeking expert advice on treatment needs for specific persons served. These
2 consultations can occur in person, by telehealth, by telephone, or by asynchronous
3 telecommunication systems.
4
5 CARE COORDINATION SERVICE
6 Care Coordination services are defined as a service that assists persons served to
7 access needed medical, educational, social, prevocational, vocational, rehabilitative, or other
8 community services.
9 Care coordination consists of activities to provide coordination of SUD care, mental
10 health care, and medical care, and to support the person served with linkages to services and
11 supports designed to restore the person served to their best possible functional level.
12 Care Coordination services are provided to a person served in conjunction with all levels
13 of treatment and may also be claimed as a standalone service.
14 Care Coordination services may be provided by an LPHA, certified counselor or
15 registered counselor. Contractors shall use care coordination services to coordinate with
16 physical and/or mental health systems of care.
17 Care coordination can be provided in clinical or nonclinical settings (including the
18 community) and can be provided face-to-face, by telehealth, or by telephone.
19
20 Care Coordination shall include one or more of the following components:
21 . Coordination with medical and mental health providers to monitor and support
22 comorbid health conditions.
• Discharge planning, including coordinating with SUD treatment providers to
23 support transitions between levels of care and to recovery resources, referrals to
mental health providers, and referrals to primary or specialty medical providers.
24 • Coordinating with ancillary services, including individualized connection, referral,
and linkages to community-based services and supports including but not limited
25 to educational, social, prevocational, vocational, housing, nutritional, criminal
26 justice, transportation, childcare, child development, family/marriage education,
cultural sources, and mutual aid support groups.
27
28 Care Coordination shall be consistent with and shall not violate confidentiality of persons
served as set forth in 42 CFR Part 2, and California law.
B-9
Exhibit B-1
1
2 REFERRAL AND INTAKE PROCESS
3 Contractor shall follow the referral and intake process as outlined in the Fresno County
4 SUD Provider Manual.
5 PROGRAM DESIGN
6 Contractor shall maintain programmatic services as described herein.
7 Contractor shall provide services allowable under their current DMC certifications. In
8 addition to services specific to Contractor's DMC certification, contractor is expected to make
9 the following services available:
• Care coordination
10
• Medication assisted treatment
11 Recovery services
12 . Peer support services
13 • Clinician Consultation
14 • Contingency management (opt in providers only)
15
DISCHARGE CRITERIA AND PROCESS
16
Contractor will engage in discharge planning beginning at intake for each person served
17 under this Agreement. Discharge planning will include regular reassessment of person served's
18 functioning, attainment of goals, determination of treatment needs and establishment of
19 discharge goals.
20 When possible, discharge will include linkage to treatment at a lower level of care or
intensity appropriate to person served's needs and provision of additional referrals and linkages
21
to community resources for person served to utilize after discharge.
22
23 CONTRACT DELIVERABLES, OBJECTIVES AND OUTCOMES
24 Contractor shall comply with all requests regarding local, state, and federal performance
25 outcomes measurement requirements and participate in the outcomes measurement processes
as requested.
26
Contractor shall work collaboratively with County to develop process benchmarks and
27 monitor progress in the following areas:
28
■ Timeliness to care standards
B-10
Exhibit B-I
1 Assessment within 10 days for Outpatient services
2 Engagement and retention in treatment
3 • No Shows/Cancellations
4 • Average length of stay
• Readmissions within 30 days
5
• Successful CalOMS discharge
6 ■ Care Coordination
7 • Referrals and linkage to other levels of care or services
8 ■ Efficiency
9 • Average annual cost of person receiving SUD services
10 • Percentage of High-Cost Utilizers
• Ratio of clinical staff to persons served
11
• Clinical staff productivity
12 ■ Surveys
13 • Increase participation in Treatment Perception Survey (TPS)
14 • Increase satisfaction reported in TPS
15 • Increase participation in Employee Engagement Survey
16 ■ Quality Assurance
• Timely chart reviews
17 Participation in person served feedback groups
18
19 Contractor will collaborate with the County in the collection and reporting of performance
20 outcomes data, including data relevant to Healthcare Effectiveness Data and Information Set
21 (HEDIS®) measures, as required by DHCS. Measures relevant to this Agreement are indicated
below:
22 Follow up After Emergency Department Visit for Alcohol and Other Drug Abuse
23 (FUA)
24 ■ Use of Pharmacotherapy for Opioid Use Disorder (POD)
25 ■ Pharmacotherapy of Opioid Use Disorder
26 ■ Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence
Treatment
27
28 REPORTING AND EVALUATION REQUIREMENTS
B-11
Exhibit B-1
1 Contractor shall complete all reporting and evaluation activities as required by the
2 County and described herein. Refer to Article 1 of this Agreement for additional information on
3 reporting and monitoring.
4 ORIENTATION, TRAINING AND TECHNICAL ASSISTANCE
5 County will endeavor to provide Contractor with training and support in the skills and
6 competencies to (a) conduct, participate in, and sustain the performance levels called for in the
7 Agreement and (b) conduct the quality management activities called for by the Agreement.
8 County will provide the Contractor with all applicable standards for the delivery and
accurate documentation of services.
9 County will make ongoing technical assistance available in the form of direct
10 consultation to Contractor upon Contractor's request to the extent that County has capacity and
11 capability to provide this assistance. In doing so, the County is not relieving Contractor of its
12 duty to provide training and supervision to its staff or to ensure that its activities comply with
13 applicable regulations and other requirements included in the terms and conditions of this
Agreement.
14 Any requests for technical assistance by Contractor regarding any part of this
15 Agreement shall be directed to the County's designated contract monitor.
16 Contractor shall require all new employees in positions designated as "covered
17 individuals" to complete compliance training within the first 30 days of their first day of work.
18 Contractor shall require all covered individuals to attend, at minimum, one compliance training
annually.
19
These trainings shall be conducted by County or, at County's discretion, by Contractor
20
staff, or both, and may address any standards contained in this Agreement.
21
Covered individuals who are subject to this training are any Contractor staff who have or
22 will have responsibility for, or who supervises any staff who have responsibility for, ordering,
23 prescribing, providing, or documenting client care or medical items or services.
24 Contractor shall require that physicians receive a minimum of five hours of continuing
25 medical education related to addiction medicine each year.
Contractor shall require that professional staff(LPHAs) receive a minimum of five hours
26
of continuing education related to addiction medicine each year.
27
28 TRANSITION OPTIMIZATION FUNDS
B-12
Exhibit B-I
1 One-time Transition Optimization Funds will be available to specialty mental health
2 providers and Drug Medi-Cal providers within FY 2023-24 to encourage Contractors to identify
3 and implement organization changes during the first year of CalAIM Payment Reform to
improve outcomes for persons served and create operational efficiencies. Contractor is
4
expected to utilize the strategies, tools and knowledge learned to their programming and
5 continue to improve services for the population served.
6
7 Drug Medi-Cal Transition Optimization funds will be provided through County
8 Realignment.
9 A. Fundinq Allocation Methodology
10 I. Each participating contractor is eligible to apply for an allocation of Transition
11 Optimization Funds up to the maximum amounts stated in Article 4 of the
12 Agreement and further described below. Transition optimization funds will
13 only be available from July 1, 2023 through June 30, 2024 and payments
shall be on a quarterly basis.
14 1. Payments will be disbursed upon review and approval by DBH of
15 each deliverable described below. Quarterly progress reports shall be
16 submitted to DBH in order to show progress as outlined in the
17 submitted plans and deliverables.
18 2. Payments will be dependent on Contractor demonstrating progress
toward meeting deliverables described in this exhibit. Contractors who
19 fail to submit progress reports by stated deadlines, or who do not
20 demonstrate adequate progress made, may be determined ineligible
21 for that quarter's payment at the sole discretion of the County.
22 3. All invoices will be submitted on a quarterly basis within fifteen (15)
23 days following the end of the quarter. Invoices submitted thereafter
may not be eligible for payment.
24
B. Responsibilities
25 I. Letter of Intent
26 Contractor shall submit a letter of intent to DBH by July 31, 2023 identifying
27 the selected Transition Optimization Activity(ies) and commitment to meet the
28 deliverable deadlines as described below. The letter shall include all current
B-13
Exhibit B-I
1 Medi-Cal billable specialty mental health and substance use disorder services
2 agreements the Contractor has with the County.
3
The County shall respond to the Contractor's letter of intent within 30
4
days. The County's response shall include a breakdown of anticipated
5 payments, as determined by the County, depending on the Transition
6 Optimization Activity(ies) chosen and depending on the number of current
7 Medi-Cal billable specialty mental health and substance use disorder
8 services agreements the Contractor has with the County.
II. Quarterly Reports
9 Contractor shall submit quarterly progress reports and invoices. Reports shall
10 be submitted on the dates indicated in the Schedule of Deliverables below.
11 Invoices are due 15 days after the end of each quarter. All activities shall be
12 completed by June 30, 2024. The report shall include updated plans/tools
13 and progress Contractor has made toward the Transition Optimization
Activity(ies) described in each Contractors' letter of intent.
14 III. Schedule of Deliverables: Equity Gap Analysis, Fiscal Monitoring Tool,
15 and Electronic Health Record
16 1. Q1 Reports: July-Sept:
17 a. Letter of Intent: Due July 31, 2023
18 b. Fiscal Monitoring Tool, Equity Gap Analysis, and Electronic
Health Record Implementation Plans (if applicable): Due
19
September 30, 2023
20 c. Fiscal Monitoring Tool Identified Practices and Strategies (if
21 applicable): Due September 30, 2023
22 2. Q2 Report: Oct-Dec: Due January 15, 2024
23 3. Q3 Report: Jan-Mar: Due April 15, 2024
4. Q4 Report: Apr-June: Due July 15, 2024
24
IV. All deliverables will be reviewed and approved by DBH prior to payment.
25
26 C. Eligible Transition Optimization Activities
27 I. Fiscal Monitoring Tools: Contractor shall submit to DBH a draft of their
28 fiscal monitoring tool that shall be used monthly on an ongoing basis to
evaluate fiscal health of the organization. Tools shall, at a minimum, monitor
B-14
Exhibit B-I
1 costs, productivity targets and identify one or more practice pattern(s) the
2 organization is employing to increase direct care time to the Medi-Cal
3 population.
1. Fiscal Monitoring Tools and Implementation Plan: Contractor shall
4 develop fiscal monitoring tools that will be used monthly to ensure
5 their organizational fiscal health and implementation plan. Fiscal
6 monitoring tools drafts and implementation plan shall be submitted to
7 DBH by September 30, 2023.
8 a. Identified Practice: Identify at least one process improvement
that shall be modified by September 30, 2023.
9 b. Quarterly Progress Reports: Quarterly progress reports shall
10 be submitted including but not limited to a narrative of
11 progress, obstacles, alternative solutions and outcomes.
12 c. Funding for this activity shall be available up to $25,000 for the
13 initial agreement with Contractor and up to another $10,000 for
each additional agreement. County shall provide further
14
details on deliverables and payment schedule in County's
15 response to the Contractor's letter of intent.
16 ll. Equity Gap Analysis: Contractor shall produce a report identifying the
17 race/ethnicity of population served in fiscal year 2022-23 compared to the
18 County's population as provided by the County. Contractor shall identify key
disparities in both persons served and amount of services and frequency of
19 transitions to other levels of care received. Contractor shall identify three (3)
20 strategies they shall employ during FY 2023-24 to reduce the disparities
21 among underserved population.
22 1. Report on Underserved Population: Contractor shall submit an Equity
23 Gap Report to the Department containing including, but not limited to,
the following:
24
a. Identify if it serves specific population within its program(s) and
25 identify whom the program(s) currently served based on data.
26 b. Staffing/workforce information and demographics. Report the
27 staffing/workforce supporting the different programs and
28 populations served by the provider in Fresno County. This
B-15
Exhibit B-I
1 data is to evaluate how the staffing reflects the populations it is
2 serving.
3 c. Comparison of the county penetration rates to the
demographics of persons served by the Contractor and
4
program(s) under agreement with DBH.
5 d. Data on retention of persons served by demographics. Total
6 persons served and the average length of stay by
7 demographics of the persons served in programs.
8 i. Which populations are remaining in the programs by
demographics, which ones are having the shortest stays.
9 ii. How long is the average length of stay by the
10 demographics.
11 e. Identify what data points the Contractor is missing at this time
12 that challenges its ability to thoroughly assess its equity gap
13 analysis. Examples: Data is not collected, Data that is missing
or under reported, data not captured in its processes, etc.
14
15 2. Equity Improvement Implementation Plan: Contractor shall submit an
16 Equity Improvement Implementation Plan related to improving health
17 equity by September 30, 2023. The plan shall include the following
18 items at a minimum:
a. Contractor shall select three strategies from below:
19
i. Plan shall include specific efforts including, but not
20 limited to, the following and timelines to increase access
21 to underserved groups.
22 1) Outreach/Engagement with underserved
23 communities
2) Active attendance/participation in DBH's
24
Diversity Equity and Inclusion (DEI) workgroup
25 3) Plan for retention of persons served in
26 programs who are underrepresented
27 4) Improvement of demographic data collection
28 including Sexual Orientation Gender Identity
(SOLI)/LGBTQ data.
B-16
Exhibit B-1
1 ii. Plan shall address workforce capacity to render services
2 to more underserved populations, through:
3 1) Development of bilingual personnel
2) Recruitment plan for more diverse workforce to
4
reflect populations served.
5 3) Training for workforce to increase capacity to
6 be culturally responsive
7 4) Development workforce pool for the future that
8 can be bilingual and bicultural
b. Timeline for each effort shall be included in the plan.
9 c. Contractor shall identify the measurement to be used
10 to demonstrate successful implementation of plan.
11 Measure may be identified by the Contractor to best
12 support their plan and goals.
13 d. Contractor shall develop and submit policies and
procedures to formally support equity effort.
14 3. Quarterly Progress Reports: Use available data including but not
15 limited to, External Quality Review Organization (EQRO) and EHR
16 data to evaluate the strategies deployed. Quarterly progress reports
17 shall be submitted including but not limited to a narrative of the
18 progress, obstacles, alternative solutions and outcomes. The final
quarter shall include a comprehensive final report on the outcomes.
19 4. Funding for this activity shall be available up to $25,000 for the initial
20 agreement with Contractor and up to another$10,000 for each
21 additional agreement. County shall provide further details on
22 deliverables and payment schedule in County's response to the
23 Contractor's letter of intent.
III. Electronic Health Record (EHR): The implementation and expansion of the
24
SmartCare EHR is an essential component of improving oversight with the
25 implementation of payment reform. Furthermore, a standardized EHR will
26 improve continuity of care, create transparency across the system, remove
27 obstacles for individuals accessing services and improve the overall
28 outcomes for persons served. For Contractors who plan to opt in to use
SmartCare or have previously opted into DBH's former EHR and intend to
B-17
Exhibit B-1
1 transition to SmartCare, user fees and costs shall be waived during FY 2023-
2 2024 and FY 2024-2025.
3 1. Option One: Current EHR Users
a. Strategic Plan: Contractors utilizing DBH's EHR as their
4
current EHR, and who will continue to utilize SmartCare
5 beginning July 1, 2023, shall provide a plan, including, but not
6 limited to, how they will optimize Medi-Cal billing, illustrate how
7 they will utilize the information in the EHR to improve care for
8 persons served, and a training plan for their organization by
September 30, 2023.
9 b. Quarterly Progress Reports: Quarterly progress reports shall
10 be submitted, including, but not limited to, a narrative on the
11 progress, obstacles, alternative solutions and outcomes.
12 c. Total compensation for this Electronic Health Record activity,
13 Option 1, shall not exceed $50,000.00 split among all current
agreements between the Contractor and the County for Medi-
14 Cal billable specialty mental health and substance use
15 disorder services. County shall provide further details on
16 deliverables and payment schedule in County's response to
17 the Contractor's letter of intent.
18 2. Option Two: Non-EHR Users
a. Contractor shall submit an implementation plan by September
19
30, 2023 regarding how they will transition to utilizing the
20 SmartCare EHR by June 30, 2024. The plan shall include, at a
21 minimum, an identified Go Live Date, plan on how the current
22 record system will be maintained and utilized, training plan
23 including number of individuals, and additional supports. The
Go Live Date must occur by June 30, 2024 to receive final
24 payment. Contractor shall work closely with DBH to identify
25 needs, assignments, collaboration opportunities to transition.
26 b. For Option 2, the Contractor shall not be reimbursed more
27 than $200,000 split among all current agreements between the
28 Contractor and the County for Medi-Cal billable specialty
mental health and substance use disorder services. The total
B-18
Exhibit B-1
1 maximum compensation available for this option, shall include
2 costs for maintaining current electronic health record/record
3 system and additional supports and training costs per user.
Contractor shall transition both specialty mental health and
4 Drug Medi-Cal programming to the County's EHR and shall be
5 required to use the County's EHR for future eligibility
6 agreements with DBH. County shall provide further details on
7 deliverables and payment schedule in County's response to
8 the Contractor's letter of intent.
9
10
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12
13
14
15
16
17
18
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20
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B-19
CO
$ Department of Exhibit C-1
Sao Behavioral Health
FRE"' PPG 1.3.14 V#: 2
Section: DBH Policies & Procedures, Mental Health, Substance Use Disorder
Effective Date: 07/09/2021 Revised Date: 01/10/2024
Policy Title: Guiding Principles of Care Delivery
Approved by:Joseph Rangel (Behavioral Health Division Manager), Lesby Flores (Licensed Deputy Director of
Behavioral Health), Stacy VanBruggen (Licensed Behavioral Health Division Manager), Susan Holt(Director of
Behavioral Health)
POLICY: The DBH Guiding Principles of Care Delivery define and guide our
Behavioral Health System of Care. We expect excellence in the provision
of behavioral health services where the values of wellness, resiliency, and
recovery are central to the development of programs, services, and
workforce.
PURPOSE: The principles provide the clinical framework that influences decision-
making in all aspects of care delivery including program design and
implementation, service delivery, training of the workforce, allocation of
resources, and measurement of outcomes.
REFERENCE: N/A
DEFINITIONS: Quadruple Aim — (1) deliver quality care, (2) maximize resources while
focusing on efficiency, (3) provide an excellent care experience, and (4)
promote workforce well-being.
PROCEDURE:
I. Principle One — Timely Access & Integrated Services
A. Persons-served are connected with services in a manner that is efficient and
effective.
B. Collaborative care coordination occurs across agencies, plans for care are
integrated, and whole person care considers all life domains such as physical
health, education,employment, housing, spirituality and other social determinant
of health.
C. Barriers to access and treatment are identified and addressed.
D. Excellent customer service ensures persons served are transitioned from one
point of care to another without disruption of care.
II. Principle Two — Strengths-Based
A. Positive change occurs within the context of genuine trusting relationships.
MISSION STATEMENT
DBH,in partnership with our diverse communities,is dedicated to providing quality,culturally responsive,behavioral health services to promote
wellness,recovery,and resiliency for individuals and families in our community.
0812021
Section: DBH Policies& Procedures, Mental Health,Substance Use
Disorder
Exhibit C-1
PPG 1.3.14 V#:2
Policy Title: Guiding Principles of Care Delivery
B. Individuals, families, and communities are resourceful and resilient in the way
they solve problems.
C. Hope and optimism are created through the identification of, and focus on, the
unique abilities of persons served.
III. Principle Three — Person-Driven and Family-Driven
A. Self-determination and self-direction are the foundations for recovery.
B. Persons served optimize their autonomy and independence by leading the
process, including the identification of strengths, needs, and preferences.
C. Providers contribute clinical expertise, provide options, and support persons
served in informed decision making, developing goals and objectives, and
identifying pathways to recovery.
D. Persons served partner with their provider(s) in determining the services and
supports that would be most effective and helpful and they exercise choice in the
services and supports they receive.
IV. Principle Four— Inclusive of Natural Supports
A. The person served identifies and defines family and other natural supports to be
included in care.
B. Persons served speak for themselves.
C. Natural support systems are vital to successful recovery and the maintaining of
ongoing wellness;these supports include personal associations and relationships
typically developed in the community that enhance a person's quality of life.
D. Providers assist persons served in developing and utilizing natural supports.
V. Principle Five — Clinical Significance and Evidence Based Practices (EBP)
A. Services are effective, resulting in a noticeable, measurable change in daily life.
B. Clinical practice is informed by best available research evidence, best clinical
expertise, and the values and preferences of those we serve.
C. Other clinically and culturally significant interventions such as innovative,
promising, and emerging practices are embraced.
VI. Principle Six — Culturally Responsive
A. Values, traditions, and beliefs specific to a person served's culture(s) are valued
and leveraged to support the theirwellness, resilience, and recovery.
B. Services are culturally grounded, congruent, and personalized to reflect the
unique cultural experience of each person served.
2 1 P a g e
Section: DBH Policies& Procedures, Mental Health,Substance Use
Disorder
Exhibit C-1
PPG 1.3.14 V#:2
Policy Title: Guiding Principles of Care Delivery
C. Providers exhibit the highest level of cultural humility and responsiveness to the
self-identified culture(s) of the person orfamily served in striving to achieve the
greatest equity in care delivery.
VII. Principle Seven — Trauma-informed and Trauma-Responsive
A. The widespread impacts of all types of trauma are recognized and the various
potential paths for recovery from trauma are understood.
B. Signs and symptoms of trauma in persons served, team members, and others
are recognized and persons served receive trauma-informed responses.
C. Physical, psychological, and emotional safety for persons served and treatment
team members is emphasized.
VIII. Principle Eight— Co-Occurring Capable
A. Services are reflective of whole-person care; providers understand the influence
of bio-psycho-social factors and the interactions between physical health, mental
health, and substance use disorders.
B. Treatment of mental health and substance use disorders are integrated. A
provider or team may deliver treatment for mental health and substance use
disorders at the same time.
IX. Principle Nine — Stages of Change, Motivation, and Harm Reduction
A. Interventions are motivation-based and adapted to the person served's stage of
change.
B. Progression through stages of change is supported through positive working
relationships and alliances that are motivating.
C. Providers support persons served to develop strategies aimed at reducing
negative outcomes of substance misuse through a harm reduction approach.
D. Each person served defines their own recovery and recovers at their own pace
when provided with sufficient dignity, time, and support.
X. Principle Ten — Continuous Quality Improvement and Outcomes-Driven
A. Individual and program outcomes are collected and evaluated for quality and
efficacy.
B. Strategies are implemented to achieve a system of continuous quality
improvement and improved performance outcomes.
C. Providers participate in ongoing professional development activities needed for
proficiency in practice and implementation of treatment models.
3 1 P a g e
Section: DBH Policies& Procedures, Mental Health,Substance Use
Disorder
Exhibit C-1
PPG 1.3.14 V#:2
Policy Title:Guiding Principles of Care Delivery
XI. Principle Eleven — Health and Wellness Promotion, Illness and Harm Prevention,
and Stigma Reduction
A. The rights of all persons served are respected and persons served are treated
with dignity.
B. Behavioral health is recognized as essential for person served and community
well-being.
C. Promotion of health and wellness is interwoven throughout all aspects of DBH
services.
D. Specific strategies to prevent illness and harm are implemented at the individual,
family, program, and community levels.
E. Stigma is actively reduced by promoting awareness and accountability through
creating positive change in attitudes, beliefs, practices, and policies within all
systems.
F. The vision of health and well-being for our community is continually addressed
through collaborations between providers, persons served, families, and
commu n ity members.
4 1 P a g e
Exhibit E-1
DRUG MEDI-CAL INTERGOVERNMENTAL AGREEMENT REQUIREMENTS
Fresno County, through the Department of Behavioral Health (DBH), makes substance use
disorder treatment services available throughout the county to Medi-Cal eligible persons served
through funds provided under an Intergovernmental Agreement with the California Department of
Health Care Services. The County, and all contracted providers, must comply with the terms of the
Intergovernmental Agreement, DHCS Behavioral Health Information Notices (BHINs), and any
amendments thereto, including but not limited to the following:
1. ADMISSION NON-DISCRIMINATION
Contractor shall not discriminate in the provision of services against Medi-Cal eligible
persons served in County who require an assessment or meet medical necessity criteria for
DMC-ODS in the provision of SUD services because of race, color, religion, ancestry, marital
status, national origin, ethnic group identification, sex, sexual orientation, gender, gender
identity, gender expression, age, medical condition, genetic information, health status or need
for health care services, mental or physical disability, or military or veteran status as provided by
State of California and Federal law in accordance with Title VI of the Civil Rights Act of 1964 (42
USC § 2000(d)); Age Discrimination Act of 1975 (42 USC § 1681); Rehabilitation Act of 1973
(29 USC § 794); Education Amendments of 1972 (20 USC § 1681); Americans with Disabilities
Act of 1990 (42 USC § 12132); 45 CFR, Part 84; provisions of the Fair Employment and
Housing Act (California Government Code § 12900); and regulations promulgated thereunder
(CCR Title 2, § 7285.0); Title 2, Division 3, Article 9.5 of the California Government Code
commencing with section 11135; and CCR Title 9, Division 4, Chapter 6 commencing with
section 10800., 42. C.F.R. §438.3(d)(3) and (4), BHIN 22-060 Enclosure 4.
Contractor shall take affirmative action to ensure that services to intended Medi-Cal
persons served are provided without use of any policy or practice that has the effect of
discriminating on the basis of race, color, religion, ancestry, marital status, national origin, ethnic
group, identification, sex, sexual orientation, gender, gender identity, age, medical condition,
genetic information, health status or need for health care services, or mental or physical
disability.
Non-Discrimination Notice: Contractor shall prepare, prominently post in its facility, and
make available to the DBH Director, or his or her designee, and to the public all eligibility
requirements to participate in the program funded under this Agreement. Contractor
Contractor shall provide information on how to file a Discrimination Grievance with
County or DHCS if there is a concern of discrimination based on sex, race, color, religion,
ancestry, national origin, ethnic group identification, age, mental disability, physical disability,
medical condition, genetic information, marital status, gender, gender identity, or sexual
orientation. Contractor shall also provide information on how to file a Discrimination Grievance
with the United States Department of Health and Human Services Office of Civil Rights if there
is a concern of discrimination based on race, color, national origin, sex, age, or disability.
2. INSPECTION AND AUDIT OF RECORDS AND ACCESS TO FACILITIES
(A) RIGHT TO MONITOR
(1) County or any subdivision or appointee thereof, and the State of California or any
subdivision or appointee thereof, including the Auditor General, shall have
1
Exhibit E-1
absolute right to review and audit all records, books, papers, documents,
corporate minutes, financial records, staff information, persons served records,
other pertinent items as requested, and shall have absolute right to monitor the
performance of Contractor in the delivery of services provided under this
Agreement. Full cooperation shall be given by the Contractor in any auditing or
monitoring conducted, according to this Agreement.
(2) Contractor shall 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 this Agreement, or determinations of amounts
payable available at any time for inspection, examination, or copying by County,
the State of California or any subdivision or appointee thereof, CMS, U.S.
Department of Health and Human Services (HHS) Office of Inspector General,
the United States Comptroller General or their designees, and other authorized
federal and state agencies. This audit right will exist for at least 10 years from the
final date of the Agreement period or in the event the Contractor has been
notified that an audit or investigation of this Agreement has 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 CFR §
438.230(c)(3)(I)-(ii)).
(3) The County, DHCS, CMS, or the HHS Office of Inspector General may inspect,
evaluate, and audit the Contractor at any time if there is a reasonable possibility
of fraud or similar risk. The Department's inspection shall occur at the
Contractor's place of business, premises or physical facilities (42 CFR §
438.230(c)(3)(iv)).
(4) Contractor shall cooperate with the County in the implementation, monitoring and
evaluation of this Agreement and comply with any and all reporting requirements
established by the County. Should the County identify an issue or receive
notification of a complaint or potential/actual/suspected violation of requirements,
the County may audit, monitor, and/or request information from the Contractor to
ensure compliance with laws, regulations, and requirements, as applicable.
(5) County reserves the right to place Contractor on probationary status, as
referenced in the Probationary Status Article, should Contractor fail to meet
performance requirements; including, but not limited to violations such as high
disallowance rates, failure to report incidents and changes as contractually
required, failure to correct issues, inappropriate invoicing, untimely and
inaccurate data entry, not meeting performance outcomes expectations, and
violations issued directly from the State. Additionally, Contractor may be subject
to probationary status or termination if contract monitoring and auditing corrective
actions are not resolved within specified timeframes.
(6) Contractor shall retain all records and documents originated or prepared
pursuant to Contractor's performance under this Agreement, including persons
served grievance and appeal records, and the data, information and
documentation specified in 42 C.F.R. parts §§ 438.604, 438.606, 438.608, and
2
Exhibit E-1
438.610 for a period of no less than 10 years from the term end date of this
Agreement or until such time as the matter under audit or investigation has been
resolved. Records and documents include but are not limited to all physical and
electronic records and documents originated or prepared pursuant to
Contractor's or subcontractor's performance under this Agreement including
working papers, reports, financial records and documents of account, person
served records, prescription files, subcontracts, and any other documentation
pertaining to covered services and other related services for persons served.
(7) Contractor shall maintain all records and management books pertaining to
service delivery and demonstrate accountability for contract performance and
maintain all fiscal, statistical, and management books and records pertaining to
the program. Records should include, but are not limited to, monthly summary
sheets, sign-in sheets, and other primary source documents. Fiscal records shall
be kept in accordance with Generally Accepted Accounting Principles and must
account for all funds, tangible assets, revenue and expenditures. Fiscal records
must also comply with the Code of Federal Regulations (CFR), Title II, Subtitle A,
Chapter 11, Part 200, Uniform Administrative Requirements, Cost Principles, and
Audit Requirements for Federal Awards.
(8) All records shall be complete and current and comply with all Agreement
requirements. Failure to maintain acceptable records per the preceding
requirements shall be considered grounds for withholding of payments for billings
submitted and for termination of Agreement.
(9) Contractor shall maintain person served and community service records in
compliance with all regulations set forth by local, state, and federal requirements,
laws and regulations, and provide access to clinical records by County staff.
Contractor shall comply with Medical Records/Protected Health Information
Article regarding relinquishing or maintaining medical records.
(10) Contractor shall agree to maintain and retain all appropriate service and
financial records for a period of at least 10 years from the date of final payment,
the final date of the contract period, final settlement, or until audit findings are
resolved, whichever is later.
(11) Contractor shall submit audited financial reports on an annual basis to the
County. The audit shall be conducted in accordance with generally accepted
accounting principles and generally accepted auditing standards.
(12) In the event the Agreement is terminated, ends its designated term or
Contractor ceases operation of its business, Contractor shall deliver or make
available to County all financial records that may have been accumulated by
Contractor or subcontractor under this Agreement, whether completed, partially
completed or in progress within seven calendar days of said termination/end
date.
(13) Contractor shall provide all reasonable facilities and assistance for the
safety and convenience of the County's representatives in the performance of
3
Exhibit E-1
their duties. All inspections and evaluations shall be performed in such a manner
that will not unduly delay the work of Contractor.
(14) County has the discretion to revoke full or partial provisions of the
Agreement, delegated activities or obligations, or application of other remedies
permitted by state or federal law when the County or DHCS determines
Contractor has not performed satisfactorily.
(B) SITE INSPECTION
Without limiting any other provision related to inspections or audits otherwise
set forth in this Agreement, Contractor shall permit authorized County, state, and/or
federal agency(ies), through any authorized representative, the right to inspect or
otherwise evaluate the work performed or being performed hereunder including
subcontract support activities and the premises which it is being performed.
Contractor shall provide all reasonable assistance for the safety and convenience of
the authorized representative in the performance of their duties. All inspections and
evaluations shall be made in a manner that will not unduly delay the work.
(C) CHART AUDITING AND REASONS FOR RECOUPMENT
(1) MAINTENANCE OF RECORDS
Contractor shall maintain proper clinical and fiscal records relating to person
served under the terms of this Agreement, as required by the Director, DHCS,
and all applicable state and federal statutes and regulations. Clinical records
shall include but not be limited to admission records, diagnostic studies and
evaluations, person served interviews and progress notes, and records of
services provided. All such records shall be maintained in sufficient detail to
permit evaluation of the services provided and to meet claiming requirements.
(2) ACCESS TO RECORDS
Contractor shall provide County with access to all documentation of services
provided under this Agreement for County's use in administering this Agreement.
Contractor shall allow County, CMS, the Office of the Inspector General, the
Controller General of the United States, and any other authorized federal and
state agencies to evaluate performance under this Agreement, and to inspect,
evaluate, and audit any and all records, documents, and the premises,
equipment and facilities maintained by the Contractor pertaining to such services
at any time and as otherwise required under this Agreement.
(3) FEDERAL, STATE AND County AUDITS
In accordance with 42 C.F.R. § 438.66 and as applicable with 42 C.F.R. §§
438.604, 438.606, 438.608, 438.610, 438.230, 438.808, 438.900 et seq., County
will conduct monitoring and oversight activities to review the Contractor's SUD
programs and operations. The purpose of these oversight activities is to verify
that medically necessary services are provided to person served, who meet
medical necessity and criteria for access to DMC-ODS as established in BHIN
24-001, in compliance with the applicable state and federal laws and regulations,
4
Exhibit E-1
and/or the terms of the Agreement between Contractor and County, and future
BHINs which may spell out other specific requirements.
(4) INTERNAL AUDITING
(a) Contractor of sufficient size as determined by County shall institute and
conduct a Quality Assurance Process for all services provided hereunder.
Said process shall include at a minimum a system for verifying that all
services provided and claimed for reimbursement shall meet DMC-ODS
definitions and be documented accurately.
(b) Contractor shall provide County with notification and a summary of any
internal audit exceptions and the specific corrective actions taken to
sufficiently reduce the errors that are discovered through Contractor's internal
audit process. Contractor shall provide this notification and summary to
County in a timely manner.
(5) CONFIDENTIALITY IN AUDIT PROCESS
(a) Contractor and County mutually agree to maintain the confidentiality of
Contractor's clinical records and information, in compliance with all applicable
state and federal statutes and regulations, including but not limited to HIPAA,
42 CFR Part 2, and California Welfare and Institutions Code, § 5328, to the
extent that these requirements are applicable. Contractor shall inform all of its
officers, employees and agents of the confidentiality provisions of all
applicable statutes.
(b) Contractor's fiscal records shall contain sufficient data to enable auditors to
perform a complete audit and shall be maintained in conformance with
standard procedures and accounting principles.
(c) Contractor's records shall be maintained as required by the Director and
DHCS on forms furnished by DHCS or the County. All statistical data or
information requested by the Director shall be provided by the Contractor in a
complete and timely manner.
(6) REASONS FOR RECOUPMENT
County will conduct periodic audits of Contractor charts to ensure appropriate
clinical documentation, high quality service provision and compliance with
applicable federal, state and county regulations.
Such audits may result in requirements for Contractor to reimburse County for
services previously paid in the following circumstances:
(a) Identification of Fraud, Waste or Abuse as defined in federal regulation.
(i) Fraud and abuse are defined in Code of Federal Regulations, Title 42, §
455.2 and Welfare & Institutions Code, § 14107.11, subdivision (d).
5
Exhibit E-1
(ii) Definitions for"fraud," "waste," and "abuse" can also be found in the
Medicare Managed Care Manual available at www.cros.gov/Regulations-
and-Guidance/Guidance/Manuals/Downloads/mc86c21.pdf.
(b) Overpayment of Contractor by County due to errors in claiming or
documentation.
(i) Contractor shall reimburse County for all overpayments identified by
Contractor, County and/or state or federal oversight agencies as an audit
exception within the timeframes required by law or Country or state or
federal agency.
(7) COOPERATION WITH AUDITS
Contractor shall cooperate with County in any review and/or audit initiated by
County, DHCS, or any other applicable regulatory body. This cooperation may
include such activities as onsite program, fiscal, or chart reviews and/or audits.
In addition, Contractor shall comply with all requests for any documentation or
files including, but not limited to, clinical and personnel files.
Contractor shall notify the County of any scheduled or unscheduled external
evaluation or site visits when it becomes aware of such visit. County shall
reserve the right to attend any or all parts of external review processes.
Contractor shall allow inspection, evaluation and audit of its records, documents
and facilities for 10 years from the term end date of this Agreement or in the
event Contractor has been notified that an audit or investigation of this
Agreement 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 pursuant to 42 C.F.R. §§ 438.3(h) and 438.230(c)(3)(i-iii).
3. SUBCONTRACTUAL REQUIREMENTS
Contractor shall fulfill contractual requirements of delegated services or activities in
accordance with 42 CFR §438.230 and shall perform the delegated activities and reporting
responsibilities in compliance with County's State-County Intergovernmental Agreement
obligations. Contractor shall comply with applicable Medi-Cal laws and regulations, as described
in this Exhibit, including applicable sub-regulatory guidance, such as Behavioral Health
Information Notices (BHINs), Mental Health and Substance Use Disorders Information Notices
(MHSUDs), and provisions of County's state or federal contracts governing person served
services.
In the event of an amendment to any law, regulation or guidance during the term of this
Agreement, the Parties agree to comply with the amended authority as of the effective date of
such amendment without amending this Agreement.
Contractor shall not bill persons served for covered services under this agreement in
excess of the amount that would be owed by the individual if the County had directly provided
the services (42 U.S.C. 1396u-2(b)(6)(C)).
6
Exhibit E-1
4. SITE LICENSE, CERTIFICATIONS AND PERMITS REQUIREMENTS
As specified in BHIN 21-001 and in accordance with Health and Safety Code
§11834.015, DHCS adopted the ASAM treatment criteria as the minimum standard of care for
licensed AOD facilities. All licensed AOD facilities shall obtain at least one DHCS LOC
Designation and/or at least one residential LOC Certification consistent with all of its program
services. If an AOD facility opts to obtain an ASAM LOC Certification, then that facility will not
be required to obtain a DHCS LOC designation. However, nothing precludes a facility from
obtaining both a DHCS LOC Designation and ASAM LOC Certification.
Contractor shall obtain and comply with DMC site certification and ASAM designation or
DHCS LOC Designation for each type of contracted service being offered, as well as any
additional licensure, registration or accreditation required by regulations for the contracted
service being delivered.
Contractor shall obtain and maintain all appropriate licenses, permits, and certificates
required by all applicable federal, state, and county and/or municipal laws, regulations,
guidelines, and/or directives.
Contractor shall have and maintain a valid fire clearance at the specified service delivery
sites where direct services are provided to persons served.
5. STATE ALCOHOL AND DRUG REQUIREMENTS
Recordkeeping Requirements
(A) Contractor shall maintain books, records, documents, and other evidence necessary to
monitor and audit this Agreement.
(B) Contractor shall maintain adequate program and fiscal records relating to individuals
served under the terms of this Agreement, as required, to meet the needs of the State
in monitoring quality, quantity, fiscal accountability, and accessibility of services.
Information on each individual shall include, but not be limited to, admission records,
patient and person served interviews and progress notes, and records of service
provided by various service locations, in sufficient detail to make possible an evaluation
of services provided and compliance with this Agreement.
(C) Contractor shall retain all person served grievance and appeals records in 42 CFR
§438.416, and the data, information, and documentation specified in 42 CFR
§§438.604, 438.606, 438.608, and 438.610 for a period of no less than ten (10) years.
Access And Cultural Considerations
Contractor shall participate in the Department's efforts to promote the delivery of services
in a culturally competent manner and provide physical access, reasonable accommodations, and
accessible equipment for Medicaid persons served with physical or mental disabilities.
Confidentiality
Contractor shall use and disclose medical records and any other health and enrollment
information that identifies a particular person served's identifiable health information in accordance
with the privacy requirements in 45 CFR parts 160 and 164, subparts A and E and 42 CFR Part 2,
7
Exhibit E-1
to the extent that these requirements are applicable
Reports
Contractor agrees to participate in surveys related to the performance of this Agreement
and expenditure of funds and agrees to provide any such information in a mutually agreed upon
format.
6. GRIEVANCE AND APPEALS RECORDKEEPING REQUIREMENTS
Contractor shall retain person served grievance and appeal records as referenced in 42
CFR §438.416, for a period of no less than ten (10) years. Person served grievance and appeal
data shall include a general description of the reason for the grievance or appeal, the date the
grievance or appeal was received, the date of each review or, if applicable, review meeting, the
resolution and date of resolution at each level of the grievance or appeal and the name of the
covered person for whom the grievance or appeal was filed. The record must be accurately
maintained in a manner accessible to DHCS and available upon request to CMS.
7. MEMBER HANDBOOK
Contractor shall utilize County developed member handbook and issue to persons
served at intake either in paper or in electronic format. Member handbooks can also be made
available by mailing a printed copy of the information to the person served's mailing address,
emailing after obtaining the person served's agreement to receive information by email,
providing direction in paper or electronic form to the County website where the handbook is
available, or any other method that can reasonably be expected to result in the person served
receiving that information.
8. ACCESS TO SUBSTANCE USE DISORDER SERVICES
(A) Contractor will work to ensure that persons served to whom the Contractor provides
SUD services met access criteria and medical necessity requirements, per DHCS
guidance specified in BHIN 24-001. Specifically, the Contractor will ensure that the
clinical record for each person served includes information as a whole indicating that
their presentation and needs are aligned with the criterial applicable to their age at
the time of service provision as specified below.
(B) Contractor shall have written admission criteria for determining the person served's
eligibility and suitability for treatment and services. All persons served admitted shall
meet the admission criteria and this shall be documented in the clinical chart.
(C) Contractor shall ensure that their policies, procedures, practices, and rules and
regulations do not discriminate against special populations. Whenever the needs of
the person served cannot be reasonably accommodated, Contractor must make
referral and linkage to an appropriate program.
(D) Contractor should recognize and educate staff and collaborative partners that Parole
and Probation status is not a barrier to SUD services.
(E) The initial assessment shall be performed face-to-face, by telehealth or by telephone
by a Licensed Practitioner of the Healing Arts (LPHA) or registered or certified
counselor and may be done in the community or the home, except for residential
8
Exhibit E-1
treatment services and narcotic treatment programs (NTPs). If the assessment of the
person served is completed by a registered or certified counselor, then an LPHA
shall evaluate that assessment with the counselor and the LPHA shall make the final
diagnosis. The consultation between the LPHA and the registered or certified
counselor can be conducted in person, by video conferencing, or by telephone.
9. TIMELY ACCESS COVERAGE AND REQUIREMENTS
(A) Contractor shall meet DHCS and County standards for timely access to care and
services, taking into account the urgency of the need for services. Contractors must
offer hours of operation that are no less than the hours of operation offered to
commercial persons served or comparable to Medicaid FFS, if Contractor serves
only Medicaid persons served. Timeliness standards include, but are not limited to:
(1) Initial contact to first face-to-face appointment— 10 business days
(2) Initial contact to first dose of NTP — 3 business days
(3) Timeliness of services for Urgent Conditions — 1 business day
Contractor shall ensure services included in this agreement are available 24 hours a
day, 7 days a week when medically necessary.
(B) Initial Assessment and Services Provided During the Assessment Process:
Covered and clinically appropriate DMC-ODS services (except for residential) shall
be reimbursable for up to 30 days following the first visit with a Licensed Practitioner
of the Healing Arts (LPHA), registered or certified AOD counselor, or Medi-Cal Peer
Support Specialist whether or not a Diagnostic and Statistical Manual (DSM)
diagnosis for Substance-Related and Addictive Disorders is established, or up to 60
days if the person served is under age 21, or if a provider documents that the person
served is experiencing homelessness and therefore requires additional time to
complete the assessment. If a person served withdraws from treatment prior to
establishing a DSM diagnosis for Substance-Related and Addictive Disorders, and
later returns, the 30-day time period starts over. The initial assessment shall be
performed face-to-face or, by telehealth (synchronous audio and video), or by
telephone (synchronous audio-only) by an LPHA or registered or certified AOD
counselor and may be done in the community or the home. If the assessment of the
person served is completed by a registered or certified AOD counselor, then the
LPHA shall evaluate that assessment with the counselor and the LPHA shall make
the initial diagnosis. The consultation between the LPHA and the registered or
certified AOD counselor may be conducted in person, by videoconferencing, or by
telephone.
The requirements for ASAM Level of Care assessment apply to NTP persons served
and settings.
(C) Diagnosis During Initial Assessment
Contractor may use the following options during the assessment phase of persons
served's treatment when a diagnosis has yet to be established as specified in BHIN
22-013.
9
Exhibit E-1
(1) ICD-10-CM codes Z55-Z65 Potential Health Hazards Related to Socioeconomic
and Psychological Circumstances: may be used by all Contractors as appropriate
during the assessment period prior to diagnosis and do not require certification
as, or supervision of, an LPHA.
(2) I CD-10-CM code Z03-89 Encounter for Observation for Other Suspected
Diseases and Conditions Ruled Out: may be used by an LPHA during the
assessment phase of a person served's treatment when a diagnosis has yet to
be established.
(3) CMS approved diagnosis code on the ICD-10-CM tabular, available in the CMS
2022 ICD-10-CM page at https://www.cros.gov/medicare/icd-10/2022-icd-10-cm,
which may include Z codes. LPHAs may use any clinically appropriate ICD-10-
CM code, for example, codes for"Other specified" and "Unspecified" disorders,
or"Factors influencing health status and contact with health services."
(D) DMC-ODS Access for Persons Served After Assessment:
(1) For persons served 21 years and older, to qualify for DMC-ODS services after
the initial assessment process, persons served 21 years of age and older shall
meet one of the following criteria:
(a) Have at least one diagnosis from the Diagnostic and Statistical Manual of
Mental Disorders (DSM) for Substance-Related and Addictive Disorders, with
the exception of Tobacco-Related Disorders and Non-Substance-Related
Disorders, or
(b) Have had at least one diagnosis from the DSM for Substance-Related and
Addictive Disorders, with the exception of Tobacco-Related Disorders and
Non-Substance-Related Disorders, prior to being incarcerated or during
incarceration, determined by substance use history.
(2) Persons served under age 21 qualify to receive all medically necessary DMC-
ODS services as required pursuant to section 1396di of Title 42 of the United
States Code. Federal EPSDT statutes and regulations require States to furnish
all Medicaid-coverable, appropriate, and medically necessary services needed to
correct and ameliorate health conditions, regardless of whether those services
are covered in the state's Medicaid State Plan. Consistent with federal guidance,
services need not be curative or completely restorative to ameliorate a mental
health condition, including substance misuse and SUDs. Services that sustain,
support, improve, or make more tolerable substance misuse or an SUD are
considered to ameliorate the condition and are thus covered as EPSDT service
(3) Consistent with W&I Code section 14184.402(f), covered SUD prevention,
screening, assessment, and treatment services are Medi-Cal reimbursable when:
(a) Services are provided prior to determination of a diagnosis or prior to
determination of whether DMC-ODS criteria are met.
(i) Clinically appropriate and covered DMC-ODS services provided to
persons served over 21 shall be reimbursable during the assessment
10
Exhibit E-1
process as described above. In addition, the Contractor shall not disallow
reimbursement for clinically appropriate and covered DMC-ODS services
provided during the assessment process if the assessment determines
that the person served does not meet the DMC-ODS access criteria after
assessment.
(ii) This does not eliminate the requirement that all Medi-Cal claims, including
DMC-ODS claims, include a CMS approved International Classification of
Diseases, Tenth Revision (ICD-10-CM) code. In cases where services
are provided due to a suspected SUD that has not yet been diagnosed,
options are available in the CMS approved ICD-10-CM code list, for
example, codes for"Other specified" and "Unspecified" disorders," or
"Factors influencing health status and contact with health services". Refer
to BHIN 22-013, for additional information regarding code selection during
the assessment period for outpatient behavioral health services.
(b) Prevention, screening, assessment, treatment, or recovery services were not
included in an individual treatment plan, or if the person served's signature
was absent from the treatment plan.
(i) Contractors are expected to implement the guidance in BHIN 22-019
related to documentation requirements that took effect as of July 1, 2022
and adopt problem lists as specified in the BHIN. Treatment plans
continue to be required for some services in accordance with federal law
including:
a. Narcotic Treatment Programs
b. Peer Support Services
(ii) The person served has a co-occurring mental health condition. Medically
necessary covered DMC-ODS services delivered by Contractor shall be
covered and reimbursable Medi-Cal services whether or not the person
served has a co-occurring mental health condition.
10. NETWORK ADEQUACY REQUIREMENTS
Pursuant to W&I Code section 14197(d)(1)(A), under Health and Safety Code (H&S
Code) section 1367.03, commencing on January 1, 2022 unless otherwise specified, Contractor
shall:
(A) Provide or arrange for the provision of covered substance use disorder services in a
timely manner appropriate for the nature of the person served condition consistent
with good professional practice (H&S Code section 1367.03(a)(1)).
(B) Establish and maintain provider networks, policies, procedures, and quality
assurance monitoring systems and processes sufficient to ensure compliance with
this clinical appropriateness standard (H&S Code section 1367.03(a)(1)).
(C) Ensure that all processes necessary to obtain covered substance use disorder
services, including, but not limited to, prior authorization processes, are completed in
a manner that assures the provision of covered substance use disorder services to a
11
Exhibit E-1
person served in a timely manner appropriate for the individual's condition and in
compliance with H&S Code section 1367.03 (H&S Code section 1367.03(a)(2)).
(D) Ensure that, if it is necessary for Contractor or a person served to reschedule an
appointment, the appointment is promptly rescheduled in a manner that is
appropriate for the persons served's health care needs, and ensures continuity of
care consistent with good professional practice, and consistent with H&S Code
section 1\367.03 and the regulations adopted thereunder (H&S Code section
1367.03(a)(3)).
(E) Ensure that interpreter services required by H&S Code section 1 367.04 of and Cal.
Code Regs., tit. 28, §1300.67.0428 are coordinated with scheduled appointments for
covered substance use disorder services in a manner that ensures the provision of
interpreter services at the time of the appointment without imposing delay on the
scheduling of the appointment (H&S Code section 1367.03(a)(4)).
(F) Ensure a non-urgent appointment with a non-physician substance use disorder
provider within ten business days of the request for the appointment (H&S Code
section 1367.03(a)(5)(E)), except under the following circumstances:
(1) The applicable 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 individual's health (H&S Code section
1367.03(a)(5)(H)).
(2) Preventive care services and periodic follow-up care, including standing referrals
to specialists for chronic conditions, periodic office visits to monitor and treat
pregnancy, cardiac, mental health, or substance use disorder conditions, and
laboratory and radiological monitoring for recurrence of disease, 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 (H&S Code section 1367.03(a)(5)(1)).
(G)Ensure that, commencing July 1, 2022, non-urgent follow up appointments with a
non-physician substance use disorder provider: within ten (10) business days of the
prior appointment for those undergoing a course of treatment for an ongoing
substance use disorder condition (H&S Code section 1367.03(a)(5)(F)), except
under the following circumstance:
(1) The applicable 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 individual's health (H&S Code section
1367.03(a)(5)(H)).
12
Exhibit E-1
(2) Arrange for the coverage through the Managed Care Plans in accordance with
subdivision H&S Code section 1374.72(d)to ensure timely access to medically
necessary covered substance use disorder services that are not available in
network within the geographic and timely access standards set by law or
regulation (H&S Code section 1367.03(a)(7)(B)).
11. PERSON SERVED RIGHTS AND PROTECTIONS
Contractor shall take all appropriate steps to fully protect person served's rights, as
specified in Welfare and Institutions Code §5325 et eq; Title 9 CCR, §§ 862, 883, 884: Title 22
CCR, §72453 and §72527; and 42 CFR § 438.100. Contractor shall comply with any applicable
Federal and state laws that pertain to person served rights and shall ensure that its employees
observe and protect those rights. Contractor shall have written policies guaranteeing the person
served's rights.
12. PERSON SERVED BILL OF RIGHTS
Contractor must comply with the California Ethical Treatment for Persons with
Substance Use Disorder Act (Act) which requires all AOD recovery or treatment facilities
licensed and/or certified by the DHCS to adopt a person served bill of rights for persons
receiving SUD treatment and to make the bill of rights available to all persons served and
prospective persons served. The bill of rights must give the person served the rights to the
following:
(A) Be treated for the life-threatening, chronic disease of substance use disorder with
honesty, respect, and dignity, including privacy in treatment and in care of personal
needs.
(B) Be informed by the treatment provider of all the aspects of treatment recommended
to the person served, including the option of no treatment, risks of treatment, and
expected result or results.
(C) Be treated by treatment providers with qualified staff.
(D) Receive evidence-based treatment.
(E) Be treated simultaneously for co-occurring behavioral health conditions, when
medically appropriate and the treatment provider is authorized to treat the person
served.
(F) Receive an individualized, outcome-driven treatment plan/problem list.
(G)Remain in treatment for as long as the treatment provider is authorized to treat the
person served.
(H) Receive support, education, and treatment for their families and loved ones, if the
treatment provider is authorized to provide these services.
(1) Receive care in a treatment setting that is safe and ethical.
(J) Be free from mental and physical abuse, exploitation, coercion, and physical
restraint.
(K) Be informed of these rights once enrolled to receive treatment, as evidenced by
written acknowledgment or by documentation by staff in the clinical chart that a
written copy of these rights were given.
(L) Be informed by the provider of the law regarding complaints, including, but not
limited to, th be informed of the address and telephone number of DHCS.
(M)Received ethical care that covers and ensures full compliance with the requirements
set forth in Chapter 5 (commencing with Section 10500) of Divsiion 4 of Title 9 of the
13
Exhibit E-I
California Code of Regulations and the alcohol and other drug program certification
standards adopted in accordance with Section 11830.1, if applicable.
Contractor will ensure any marketing or advertising materials published or
disseminated provides accurate and complete information, includes plain language that is easy
to understand. Marketing or advertising materials shall include both of the following:
(A) Information about the types and methods of services provided or used, and
information about where they are provided, using the categories of treatment
identified in subdivision (a) of Section 11834.26 and the levels of care established
pursuant to subdivision (a) of Section 11834.015 (i.e. treatment, recovery or
detoxification services, etc.).
(B) The treatment provider's name and brand.
13. ADVERTISING REQUIREMENTS
(A) Contractor, to protect the health, safety, and welfare of persons served with a SUD,
shall not use false or misleading advertisement for their medical treatment or medical
services as per SIB 434 Health and Safety Code § 11831.9 and BHINs 22-022 and
23-045.
(B) Licensed SUD recovery or treatment facilities and certified alcohol or other drug
programs shall not do any of the following:
(1) Make a false or misleading statement or provide false or misleading statements,
or provide information about the nature, identity, or location of substance use
disorder treatment services in in its marketing, advertising materials, on a call
line, or media, or on its internet website or on a third-party internet website.
(2) Make a false or misleading statements about their status as an in-network or out-
of-network status.
(3) Allow a person or entity to provide, or direct any other person or entity to provide,
false or misleading information about the identity of, or contract information for,
any program.
(4) Include on its internet website a picture, description, staff information, or the
location of an entity, along with false contact information that surreptitiously
directs the reader to a business that does not have a contract with the entity.
(5) Include on its internet website false information or an electronic link that provides
false information or surreptitiously directs the reader to another internet website.
(6) Allow a person or entity from suggesting or implying that a relationship with a
treatment provider exists, unless the treatment provider has provided express,
written consent to indicate that relationship.
(7) Allow a person or entity working within a licensed or certified AOD recovery or
treatment facility from making a false or misleading statement about SUD
treatment services.
14
Exhibit E-1
(C) Contractor shall comply with these requirements and any subsequent regulations
around advertising requirements for SUD recovery or treatment facilities issued by
DHCS.
(D) Any actions in violation of the ACT, deemed to be deceptive may result in legal
actions and penalties.
14. PROVIDER-PERSON SERVED COMMUNICATIONS
Contractor is not restricted from acting within the lawful scope of practice, from advising
or advocating on behalf of a person served who is their patient, for the following the person
served's health status, medical care, or treatment options, including any alternative treatment
that may be self-administered, any information the person served needs to decide among all
relevant treatment options, the risks, benefits, and consequences of treatment or non-treatment,
or the person served's right to participate in decisions regarding their health care, including the
right to refuse treatment, and to express preferences about future treatment decisions.
15. LIABILITY FOR PAYMENT
Contractor shall ensure that persons served are not held liable for any of the following:
(A) Contractor's debts, in the event of the Contractor's insolvency.
(B) Covered services provided to the person served for which the state does not pay the
Contractor or the Contractor or the County does not pay the individual or health care
provider that furnished the service under a contractual referral or other obligation.
(C) Payments for covered services furnished under a contract, referral, or other
arrangement, to the extent that those payments are in excess of the amount the
person served would owe if the Contractor covered the services directly.
16. CARE COORDINATION
Contractor and County shall comply with the care and coordination requirements of the
State-County Intergovernmental Agreement, Exhibit A, Attachment I, II.E.3 and 42 C.F.R.
§438.208. Contractor shall ensure that each person served has an ongoing source of care
appropriate to his or her needs and shall ensure a person or entity within their organization is
formally designated as primarily responsible for coordinating the services accessed by the
person served. The person served shall be provided information on how to contact their case
manager. Contractor shall coordinate services: between care settings, including appropriate
discharge planning for short-term and long-term hospital and institutional stays; with services
the person served receives from any other managed care organization; with the services the
person served receives in FFS Medi-Cal; and the services the person served receives from
community and social support providers. Care coordination efforts shall be accurately
documented in person served's chart to be verified during County chart audits conducted at
least annually.
Contractor shall engage in care coordination activities beginning at intake and
throughout the treatment and discharge planning processes.
15
Exhibit E-1
To facilitate care coordination, Contractor will request a HIPAA and California law
compliant authorization to share information with and among all other providers involved in the
person served's care, in satisfaction of state and federal privacy laws and regulations.
Contractor shall make a best effort to conduct an initial screening of each person
served's ancillary needs, within thirty (30) calendar days of the effective date of admission for all
new persons served, including subsequent attempts if the initial attempt to contact the person
served is unsuccessful.
Contractor shall ensure that it maintains and shares, as appropriate, a person served
health record in accordance with professional standards.
Contractor shall ensure that in the process of coordinating care, each person served's
privacy is protected in accordance with the privacy requirements in 45 CFR parts 160 and 164
subparts A and E and 42 CFR Part 2, to the extent that they are applicable.
Contractor shall ensure that persons served are aware of and are referred to, when
appropriate, recovery supports and services immediately after discharge or upon completion of
an acute care stay.
In addition to the requirements outlined in Article III.G of Exhibit A, Attachment I,
Contractor shall comply with the following requirements for transitioning persons served to other
levels of care:
(A) Contractor's care coordinators shall ensure the transition of the person served to an
appropriate LOC. This may include step-up or step-down in covered DMC-ODS
services. Care coordinators shall provide warm hand-offs and transportation to the
new LOC when medically necessary.
(B) Contractor's care coordinators shall ensure transitions to other LOCs occur no later
10 days from the time of assessment or reassessment with no interruption of current
treatment services.
(C)The initial treating provider shall be responsible for arranging care coordination
services and communicating with the next provider to ensure smooth transitions
between LOCs.
17. SCREENING AND ENROLLMENT REQUIREMENTS
County shall ensure that all Contractor providers are enrolled with the state as Medi-Cal
providers consistent with the provider disclosure, screening, and enrollment requirements of 42
C.F.R. Part 455, subparts B and E. (42 C.F.R. § 438.608(b)).
County may execute this Agreement, pending the outcome of screening, enrollment, and
revalidation of Contractor, of up to 120 days but must terminate this Agreement immediately
upon determination that Contractor cannot be enrolled, or the expiration of one 120-day period
without enrollment of the Contractor, and notify affected persons served (42 C.F.R. §
438.602(b)(2)).
Contractor shall ensure that all Providers and/or subcontracted Providers consent to a
criminal background check, including fingerprinting to the extent required under state law and 42
16
Exhibit E-1
C.F.R. § 455.434(a). Contractor shall provide evidence of completed consents when requested
by the County, DHCS or the US Department of Health & Human Services (US DHHS).
18. TRANSITION OF CARE
Contractor shall follow County's transition of care policy in accordance with applicable
state and federal regulations, MHSUDS IN 18-051: DMC-ODS Transition of Care Policy, and
any BHINs issued by DHCS for parity in SUD and mental health benefits subsequent to the
effective date of this Agreement (42 C.F.R. § 438.62(b)(1)-(2).)
Persons served shall be allowed to continue receiving covered DMC-ODS services with
an out-of-network provider when their assessment determines that, in the absence of continued
services, the person served would suffer serious detriment to their health or be at risk of
hospitalization or institutionalization. DMC-ODS treatment services with the existing provider
(out-of-network) provider shall continue for a period of no more than 90 days unless medical
necessity requires the services to continue for a longer period of time, not exceeding 12 months.
Specific criteria must be met.
19. AUTHORIZATION OF SERVICES
Contractor shall adhere to County's written policies and procedures, outlined in the
Provider Manual, for authorization of services.
Contractor shall respond to County or administrative services organization in a timely
manner when consultation is necessary to make appropriate authorization determinations.
County or administrative services organization shall provide Contractor with written
notice of authorization determinations within the timeframes set forth in BHIN 24-001, or any
subsequent DCHS notices.
Contractor is not required to obtain service authorization for non-residential/non-inpatient
levels of care. Prior authorization is prohibited for non-residential DMC-ODS services.
(A) SUD Residential and Inpatient Levels of Care service authorization
Contractor shall have in place, and follow, County written authorization policies and
procedures for processing requests for initial and continuing authorization, or prior
authorization, for residential treatment services, including inpatient services, but
excluding withdrawal management services.
County will review the DSM and ASAM Criteria to ensure that the person served
meets the requirements for the service.
Prior authorization for residential and inpatient services (excluding withdrawal
management services) shall be made within 24 hours of the prior authorization
request being submitted by the provider.
County will ensure that prior authorization processes are completed in a manner that
assures the provision of a covered SUD service to a person served in a timely
manner appropriate for the person served's condition.
Contractor shall alert County when an expediated service authorization decision is
necessary due to a person served's specific needs and circumstances that could
17
Exhibit E-1
seriously jeopardize their life or health, or ability to attain, maintain, or regain
maximum function. Expediated service authorizations shall not exceed 72 hours after
receipt of the request for service, with a possible extension of up to 14 calendar days
if the person served or provider requests an extension.
Contractor shall alert County when a standard authorization decision is necessary.
Standard service authorizations shall not exceed 14 calendar days following receipt
of the request for service, with a possible extension of up to 14 additional calendar
days if the person served or provider requests an extension.
Contractor, if applicable, shall ensure that length of stay (LOS) in residential program
complies with the following:
(1) LOS shall be determined by individualized clinical need (statewide LOS goal is 30
days). LOS for persons served shall be determined by an LPHA and authorized
by the County as medically necessary.
(2) Persons served receiving residential treatment must be transitioned to another
LOC when clinically appropriate based on treatment progress.
(3) Perinatal persons served may receive a longer LOS than those described above,
if determined to be medically necessary.
(4) Nothing in this section overrides any EPSDT requirements. EPSDT persons
served may receive a longer length of stay based on medical necessity.
20. DOCUMENTATION REQUIREMENTS
Contractor agrees to comply with documentation requirements set
forth in this section, in compliance with federal, state and County
requirements.
(A) All Contractor documentation shall be accurate, complete, legible, and shall list each
date of service. Contractor shall document the face-to-face duration of the service,
including travel and documentation time for each service. Services must be identified
as provided in-person, by telephone, or by telehealth.
(B) All services shall be documented utilizing County-approved templates and contain all
required elements. Contractor agrees to satisfy the chart documentation
requirements set forth in BHIN 22-019 and the contract between County and DHCS.
Failure to comply with documentation standards specified herein require corrective
action plans.
21. ASSESSMENT
Contractor shall use the American Society of Addiction Medicine (ASAM) Criteria
assessment for DMC-ODS persons served to determine the appropriate level of SUD
care.
(A) The assessment shall include a typed or legibly printed name, signature of the
service provider and date of signature. Assessment shall include the provider's LOC
determination and recommendation for services. If the assessment of the person
18
Exhibit E-1
served is completed by a registered or certified counselor, then the LPHA shall
evaluate that assessment with the counselor and the LPHA shall make the initial
diagnosis. The consultation between the LPHA and the registered or certified
counselor can be conducted in person, by video conferencing, or by telephone.
(B) The problem list and progress note requirements shall support the medically
necessary services or medical necessity of each service provided.
(C)Assessments shall be updated as clinically appropriate when the person served's
condition changes. Additional information on assessment requirements can be found
in Section 9, Timely Access Coverage and Requirements, or BHIN 24-001.
22. ICD-10-CM
Contractor shall use the criteria set forth in the current edition of the DSM as the clinical
tool to make diagnostic determinations.
Once a DSM diagnosis is determined, the Contractor shall determine the corresponding
diagnosis in the current edition of ICD-10-CM. Contractor shall use the ICD-10-CM code(s) to
submit a claim for SUD services to receive reimbursement from County.
Under the EPSDT mandate, for youth under the age of 21, a diagnosis from the ICD-10-
CM for Substance-Related and Addictive Disorders is not required for early intervention
services.
The ICD-10-CM Tabular List of Diseases and Injuries is maintained by CMS and may be
updated during the term of this Agreement. Changes to the lists of ICD-10-CM codes do not
require an amendment to this Agreement, and County may implement these changes as
provided by DHCS.
23. PROBLEM LIST
(A) Contractor will create and maintain a Problem List for each person served under this
Agreement. The problem list is a list of symptoms, conditions, diagnoses, and/or risk
factors identified through assessment, psychiatric diagnostic evaluation, crisis
encounters, or other types of service encounters.
(B) Contractor must document a problem list that adheres to industry standards utilizing
at minimum SNOMED International, Systematized Nomenclature of Medicine Clinical
Terms (SNOMED CTO) U.S. Edition, March 2021 Release, and ICD-10-CM 2023.
(C)A problem identified during a service encounter may be addressed by the service
provider (within their scope of practice) during that service encounter and
subsequently added to the problem list.
(D)The problem list shall be updated on an ongoing basis to reflect the current
presentation of the person served.
(E) The problem list shall include, but is not limited to the following:
(1) Diagnoses identified by a provider acting within their scope of practice, if any.
Diagnosis-specific specifiers from the current DSM shall be included with the
diagnosis, when applicable.
19
Exhibit E-I
(2) Problems identified by a provider acting within their scope of practice, if any.
(3) Problems or illnesses identified by the person served and/or significant support
person, if any.
(4) The name and title of the provider that identified, added, or removed the problem,
and the date the problem was identified, added, or removed.
(F) Contractor shall add to or remove problems from the problem list when there is a
relevant change to a person served's condition.
(G)County does not require the problem list to be updated within a specific timeframe or
have a requirement about how frequently the problem list should be updated after a
problem has initially been added. However, Contractor shall update the problem list
within a reasonable time such that the problem list reflects the current issues facing
the person served, in accordance with generally accepted standards of practice and
in specific circumstances specified in BHIN 22-019.
24. PROGRESS NOTES
Contractor shall create progress notes for the provision of all DMC-ODS services
provided under this Agreement.
Each progress note shall provide sufficient detail to support the service code selected for
the service type as indicated by the service code description.
(A) Progress notes shall include all elements specified in BHIN 22-019, whether the note
be for an individual or group service, and shall include:
(1) The type of service rendered
(2) A narrative describing the service, including how the service addressed the
person served's behavioral health need (e.g., symptom, condition, diagnosis,
and/or risk factors)
(3) The date that the service was provided to the person served
(4) Duration of the service, including travel and documentation time
(5) Location of the person served at the time of receiving the service
(6) A typed or legibly printed name, signature of the service provider and date of
signature
(7) ICD-10-CM code
(8) Current Procedural Terminology (CPT) or Healthcare Common Procedure
Coding System (HCPCS) code
(9) Next steps, including, but not limited to, planned action steps by the provider or
by the person served, collaboration with the person served, collaboration with
other provider(s) and any update to the problem list as appropriate.
20
Exhibit E-1
(B) Contractor shall complete progress notes within three business days of providing a
service, with the exception of notes for crisis services, which shall be completed
within 24 hours.
(C) Contractor shall complete a daily progress note for services that are billed on a daily
basis, such as residential and inpatient services, if applicable.
(D)When a group service is rendered by the Contractor, the following conditions shall be
met:
(1) A list of persons served is required to be documented and maintained by the
Contractor.
(2) If more than one provider renders a group service, one progress note may be
completed for a group session and signed by one provider. Contractor shall
ensure that in this case, the progress note clearly documents the specific
involvement and the specific amount of time of involvement of each provider
during the group activity, including documentation time.
25. PLAN OF CARE
As specified in BHIN 22-019, when a plan of care is required, Contractor shall follow the
DHCS requirements outlined in the Alcohol and/or Other Drug Program Certification Standards
document, available in the DHCS Facility Certification page at:
https://www.dhcs.ca.gov/Drovgovpart/Pages/Licensing-and-Certification-Facility-
Certification.aspx
(A) Contractor shall develop plans of care for all persons served, when required, and
these plans of care shall include the following:
(1) Statement of problems experienced by the person served to be addressed.
(2) Statement of objectives to be reached that address each problem.
(3) Statement of actions that will be taken by the program and/or person served to
accomplish the identified objectives.
(4) Target date(s) for accomplishment of actions and objectives.
(B) Contractor shall develop the plan of care with participation from the person served in
accordance with the timeframes specified below:
(1) For outpatient programs, the plan of care shall be developed within 30 calendar
days from the date of the person served's admission. The person served's
progress shall be reviewed and documented within 30 calendar days after
signing the plan of care and not later than every 30 calendar days thereafter.
(2) For residential programs, the plan of care shall be developed within 10 calendar
days from the date of the person served's admission.
(3) An LPHA, registered or certified counselor shall ensure and document, that
together with the person served, the plan of care is reviewed and updated, as
necessary, when a change in problem identification or focus of treatment occurs,
21
Exhibit E-1
or no later than 90 calendar days after signing the plan of care and no later than
every 90 calendar days thereafter, whichever comes first.
(C) Contractor is not required to complete a plan of care for person served under this
Agreement, except in the below circumstances:
(1) Peer Support Services require a specific care plan based on an approved Plan of
Care. The plan of care shall be documented within the progress notes in the
person served's clinical record and approved by any treating provider who can
render reimbursable Medi-Cal services.
(2) Narcotic Treatment Programs (NTP) are required to create a plan of care for
persons served as per federal law. This requirement is not impacted by the
documentation requirements in BHIN 22-019. NTPs shall continue to comply with
federal and state regulations regarding plans of care and documentation
requirements.
26. TELEHEALTH
Contractor may use telehealth, when it deems clinically appropriate, as a mode
of delivering behavioral health services in accordance with all applicable County, state,
and federal requirements, including those related to privacy/security, efficiency, and
standards of care. Such services will conform to the definitions and meet the
requirements included in the Medi-Cal Provider Manual: Telehealth, available in the
DHCS Telehealth Resources page at:
https://www.dhcs.ca.gov/provgovpart/Pages/TelehealthResources.aspx.
All telehealth equipment and service locations must ensure that person served
confidentiality is maintained.
Licensed providers and staff may provide services via telephone and telehealth
as long as the service is within their scope of practice.
Medical records for persons served by Contractor under this Agreement must
include documentation of written or verbal consent for telehealth or telephone services if
such services are provided by Contractor. Such consent must be obtained at least once
prior to initiating applicable health care services and consent must include all elements
as specified in BHIN 22-019.
County may at any time audit Contractor's telehealth practices, and Contractor
must allow access to all materials needed to adequately monitor Contractor's adherence
to telehealth standards and requirements.
27. DISCHARGE PLANNING
Contractor shall have written policies and procedures or shall adopt the County's
policies and procedures regarding discharge. These procedures shall contain the
following:
(A) Written criteria for discharge defining:
(1) Successful completion of program;
22
Exhibit E-1
(2) Administrative discharge;
(3) Involuntary discharge;
(4) Transfers and referrals.
(B) A discharge summary that includes:
(1) Reason for discharge, including whether the discharge was voluntary or
involuntary and whether the person served successfully completed the program;
(2) Description of treatment episodes;
(3) Description of recovery services completed;
(4) Current alcohol and/or other drug usage;
(5) Vocational and educational achievements;
(6) Persons served continuing recovery or discharge plan signed by an LPHA, or
registered or certified counselor and person served;
(7) Transfers and referrals; and
(8) Person served's comments.
28. CREDENTIALING/RECREDENTIALING
Contractor shall follow the County's established credentialing and re-credentialing
process for all licensed and/or certified staff network providers, including disciplinary actions
such as reducing, suspending, or terminating provider's privileges. Failure to comply with
specified requirements can result in suspension or termination of a provider. Initial credentialing
must be completed prior to providing treatment services.
Upon request, the Contractor must demonstrate to the County that each of its providers
are qualified in accordance with current legal, professional, and technical standards, and that
they are appropriately licensed, registered, waivered, and/or certified.
Contractor must not employ or subcontract with providers debarred, suspended or
otherwise excluded (individually, and collectively referred to as "Excluded") from participation in
Federal Health Care Programs, including Medi-Cal/Medicaid or procurement activities, as set
forth in 42 C.F.R. § 438.610. See relevant section below regarding specific requirements for
exclusion monitoring.
Contractor shall ensure that all of their network providers, delivering covered services,
sign and date an attestation statement on a form provided by County, in which each provider
attests to the following:
(A) Any limitations or inabilities that affect the provider's ability to perform any of the
position's essential functions, with or without accommodation;
(B) A history of loss of license or felony convictions;
(C)A history of loss or limitation of privileges or disciplinary activity;
23
Exhibit E-1
(D)A lack of present illegal drug use; and
(E) The application's accuracy and completeness
Contractor must file and keep track of attestation statements for all of their providers and
must make those available to the County upon request at any time.
Contractor is required to sign an annual attestation statement at the time of Agreement
renewal in which they will attest that they will follow County's Credentialing Policy and MHSUDS
IN 18-019 and ensure that all of their rendering providers are credentialed as per established
guidelines.
Contractor is required to verify and document at a minimum every three years that each
network provider that delivers covered services continues to possess valid credentials, including
verification of each of the credentialing requirements as per the County's uniform process for
credentialing and recredentialing. If any of the requirements are not up-to-date, updated
information should be obtained from network providers to complete the re-credentialing process.
29. QUALITY IMPROVEMENT PROGRAM
(A) QUALITY IMPROVEMENT ACTIVITIES AND PARTICIPATION
(1) Contractor shall comply with the County's ongoing comprehensive Quality
Assessment and Performance Improvement (QAPI) Program (42 C.F.R. §
438.330(a)) and work with the County to improve established outcomes by
following structural and operational processes and activities that are consistent
with current practice standards.
(2) Contractor shall participate in quality improvement (QI) activities, including
clinical and non-clinical performance improvement projects (PIPs), as requested
by the County in relation to state and federal requirements and responsibilities, to
improve health outcomes and person serveds' satisfaction over time. Other QI
activities include quality assurance, collection and submission of performance
measures specified by the County, mechanisms to detect both underutilization
and overutilization of services, person served and system outcomes, utilization
management, utilization review, provider appeals, provider credentialing and re-
credentialing, and person served grievances. Contractor shall measure, monitor,
and annually report to the County its performance.
(3) Contractor shall implement mechanisms to assess person served/family
satisfaction based on County's guidance. The Contractor shall assess person
served/family satisfaction by:
(a) Surveying person served/family satisfaction with the Contractor's services at
least annually.
(b) Evaluating person served grievances, appeals and State Hearings at least
annually.
(c) Evaluating requests to change persons providing services at least annually.
24
Exhibit E-I
(d) Informing the County and persons served of the results of s/family
satisfaction activities.
Contractor, if applicable, shall implement mechanisms to monitor the safety and
effectiveness of medication practices. This mechanism shall be under the supervision of a
person licensed to prescribe or dispense prescription drugs, at least annually.
(1) Contractor shall implement mechanisms to monitor appropriate and timely
intervention of occurrences that raise quality of care concerns. The Contractor
shall take appropriate follow-up action when such an occurrence is identified.
The results of the intervention shall be evaluated by the Contractor at least
annually and shared with the County.
(2) Contractor shall collaborate with County to create a QI Work Plan with
documented annual evaluations and documented revisions as needed. The QI
Work Plan shall evaluate the impact and effectiveness of its quality assessment
and performance improvement program.
(3) Contractor shall attend and participate in the County's Quality Improvement
Committee (QIC) to recommend policy decisions, review and evaluate results of
QI activities, including PIPs, institute needed QI actions, and ensure follow-up of
QI processes. Contractor shall ensure that there is active participation by the
Contractor's practitioners and providers in the QIC.
(4) Contractor shall assist County, as needed, with the development and
implementation of Corrective Action Plans.
(5) Contractor shall participate, as required, in annual, independent external quality
reviews (EQR) of the quality, timeliness, and access to the services covered
under this Contract, which are conducted pursuant to Subpart E of Part 438 of
the Code of Federal Regulations. (42 C.F.R. §§ 438.350(a) and 438.320)
(B) NETWORK ADEQUACY
(1) Contractor shall ensure that all services covered under this Agreement are
available and accessible to persons served in a timely manner and in accordance
with the network adequacy standards required by regulation. (42 C.F.R. §
438.206 (a),(c)).
(2) Contractor shall submit, when requested by County and in a manner and format
determined by the County, network adequacy certification information to County,
utilizing a provided template or other designated format.
(3) Contractor shall submit updated network adequacy information to the County any
time there has been a significant change that would affect the adequacy and
capacity of services. Significant changes include, but are not limited to, changes
in services or providers available to persons served, and changes in geographic
service area.
(C)TIMELY ACCESS
25
Exhibit E-1
(1) Contractor shall comply with the requirements set forth in CCR, Title 9, §
1810.405, including meeting County and State Contract standards for timely
access to care and services, taking into account the urgency of the need for
services. County shall monitor Contractor to determine compliance with timely
access requirements and shall take corrective action in the event of
noncompliance.
(2) Timely access standards include:
(a) Contractors must have hours of operation during which services are provided
to Medi-Cal persons served that are no less than the hours of operation
during which the Contractor offers services to non-Medi-Cal persons served.
If the Contractor's provider only serves Medi-Cal persons served, the provider
must provide hours of operation comparable to the hours the Contractor
makes available for Medi-Cal services that are not covered by the Agreement
or another County.
(b) Appointments data, including wait times for requested services, must be
recorded and tracked by Contractor, and submitted to the County on a
monthly basis in a format specified by the County. Appointments' data should
be submitted to the County's Quality Management department or other
designated persons.
(c) Contractor shall ensure that all persons served seeking NTP services are
provided with an appointment within three business days of a service request.
(d) Contractor shall ensure that all persons served seeking outpatient and
intensive outpatient (non-NTP) services are provided with an appointment
within 10 business days of a non-NTP service request.
(e) Contractor shall ensure that all persons served seeking non-urgent
appointments with a non-physician SUD provider are provided within 10
business days of the request for the appointment. Similarly, Contractor shall
ensure that all persons served seeking non-urgent follow-up appointments
with a non-physician SUD provider are provided within 10 business days of
the prior appointment for those undergoing a course of treatment for an
ongoing SUD condition. These timely standards must be followed, except in
the following circumstances:
(i) The referring or treating licensed health care provider, or the health
professional providing triage or screening services, as applicable, has
determined and noted that in the relevant record that a longer waiting time
will not have a detrimental impact on the persons served's health.
(ii) Preventive care services and periodic follow-up care, including office visits
for SUD 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.
26
Exhibit E-1
(f) Contractor shall ensure that, if necessary for a person served or a provider to
reschedule an appointment, the appointment is promptly rescheduled in a
manner that is appropriate for the person served's health care needs and
ensures continuity of care consistent with good professional practice.
(g) Contractor shall ensure that during normal business hours, the waiting time
for a person served to speak by telephone with staff knowledgeable and
competent regarding the person served's questions and concerns does not
exceed 10 minutes.
(D) DATA REPORTING REQUIREMENTS
(1) Contractor shall comply with data reporting compliance standards as established
by DHCS and/or SAMHSA depending on the specific source of funding.
(2) Contractor shall ensure that all data stored or submitted to the County, DHCS or
other data collection sites is accurate and complete.
(a) California Outcomes Measurement System Treatment (CaIOMS Tx)
(i) CalOMS Tx data shall be submitted by Contractor to DHCS via electronic
submission within 45 days from the end of the last day of the report
month. This data shall be submitted during this time frame.
(b) Drug and Alcohol Treatment Access Report (DATAR)
(i) DATAR data shall be submitted by Contractor as specified by County,
either directly to DHCS or by other means established by County, by the
10th of the month following the report activity month.
(3) Substance Abuse and Prevention Treatment Block Grant (SABG) Funding
reporting
(a) Contractors providing services to persons served in counties using SABG
funds will collect and report performance data to County monthly.
(E) TREATMENT PERCEPTION SURVEY (TPS)
Contractor shall conduct the annual Treatment Perception Survey (TPS) consistent with
DMC-ODS requirements and under the direction of County.
(F) PRACTICE GUIDELINES
(1) Contractor shall adopt practice guidelines (or adopt County's practice guidelines)
that meet the following requirements as per 42 C.F.R. § 438.236:
(a) Are based on valid and reliable clinical evidence or a consensus of providers
in the field.
(b) Consider the needs of the Contractor's persons served
(c) Are adopted in consultation with network providers
(d) Are reviewed and updated periodically as appropriate
27
Exhibit E-1
(2) Contractor shall disseminate the guidelines to all affected providers and, upon
request, to persons served and potential persons served.
(G)EVIDENCE-BASED PRACTICES (EBPs)
(1) Contractors will comply with County and DHCS standards related to Evidenced
Based Practices (EBPs).
(2) Contractor will implement at least two of the following EBP to fidelity per provider,
per service modality:
(a) Motivational Interviewing
(b) Cognitive-Behavioral Services
(c) Relapse Prevention
(d) Trauma-Informed Treatment
(e) Psycho-Education
30. GRIEVANCES, APPEALS AND NOTICES OF ADVERSE BENEFIT DETERMINATION
Contractor shall comply with Grievance procedures set forth in the State-County
Intergovernmental Agreement, the Provider Manual and the Member Handbook.
All grievances (as defined by 42 C.F.R. §438.400) and complaints received by
Contractor must be immediately forwarded to the County's Quality Management Department or
other designated persons via a secure method (e.g., encrypted email or by fax) to allow ample
time for the Quality Management staff to acknowledge receipt of the grievance and complaints
and issue appropriate responses.
Contractor shall not discourage the filing of grievances and persons served do not need
to use the term "grievance" for a complaint to be captured as an expression of dissatisfaction
and, therefore, a grievance.
Aligned with MHSUDS 18-010E and 42 C.F.R. §438.404, the appropriate and delegated
Notice of Adverse Benefit Determination (NOABD) must be issued by Contractors within the
specified timeframes using the template provided by the County.
NOABDs must be issued to persons served anytime the Contractor has made or intends
to make an adverse benefit determination that includes the reduction, suspension, or
termination of a previously authorized service and/or the failure to provide services in a timely
manner. The notice must have a clear and concise explanation of the reason(s) for the decision
as established by DHCS and the County. The Contractor must inform the County immediately
after issuing a NOABD.
Procedures and timeframes for responding to grievances, issuing, and responding to
adverse benefit determinations, appeals, and state hearings must be followed as per 42
C.F.R., Part 438, Subpart F (42 C.F.R. §§ 438.400—438.424).
Contractor must provide person served with any reasonable assistance in completing
forms and taking other procedural steps related to a grievance or appeal such as auxiliary aids
and interpreter services.
28
Exhibit E-1
Contractor must maintain records of grievances and appeals and must review the
information as part of its ongoing monitoring procedures. The record must be accurately
maintained in a manner accessible to the County and available upon request to DHCS.
Contractor shall log complaints and the disposition of all complaints from a person
served or a person served's family. Contractor shall provide a summary of the complaint log
entries concerning County-sponsored persons served to County at monthly intervals by the
fifteenth (151h) day of the following month, in a format that is mutually agreed upon. Contractor
shall post signs informing persons served o their right to file a complaint or grievance.
Contractor shall notify County of all incident reportable to state licensing bodies that affect
County persons served within twenty-four (24) hours of receipt of a complaint.
Withing fifteen (15) days after each incident or complaint affecting County-sponsored
persons served, Contractor shall provide County with information relevant to the complaint,
investigative details of the complaint, the complaint and Contractor's disposition of, or
corrective action taken to resolve the complaint.
Contractor shall make the following grievance information available to all persons
served:
(A) Right to a State Fair Hearing and how to obtain a hearing as well as representation
rules.
(B) Right to file grievances and appeals, including the requirements and timeframes for
filing.
(C) Right to give written consent to allow Contractor or legal representative, acting on
behalf of the person served, to file an appeal.
(D) Grievance can be filed orally or in writing to DHCS or County.
(E) The availability of assistance with filing grievances and appeals.
(F) The toll-free number to file oral grievances and appeals.
(G)Right to request continuation of benefits during an appeal or state fair hearing filing
although the person served may be liable for the cost of any continued benefits if the
action is upheld.
(H)Any state determined Contractor's appeal rights to challenge the failure of the
County to cover a service.
31. ADVANCED DIRECTIVES
Contractor must comply with all County policies and procedures regarding Advanced
Directives in compliance with the requirements of 42 C.F.R. §§ 422.128 and 438.6(i) (1), (3) and
(4).
32. PROGRAM INTEGRITY REQUIREMENTS
(A) GENERAL
Contractor shall implement and maintain arrangements or procedures that are designed
to detect and prevent fraud, waste, and abuse. Contractor shall maintain written policies,
29
Exhibit E-1
procedures, and standards of conduct that articulate Contractor's commitment to comply with all
applicable requirements and standards under the State-County Intergovernmental Agreement,
and all applicable Federal and State requirements. Contractor shall establish and implement
procedures and a system with dedicated staff for routine internal monitoring and auditing of
compliance risks, prompt response to compliance issues as they are raised, investigation of
potential compliance problems as identified in the course of self-evaluation and audits,
correction of such problems promptly and thoroughly (or coordination of suspected criminal acts
with law enforcement agencies) to reduce the potential for recurrence, and ongoing compliance.
Contractor shall provide reports to County within 60 calendar days when it has identified
an overpayment. County shall provide a mechanism for reporting and collecting overpayment.
As a condition of receiving payment under a Medi-Cal managed care program, the
Contractor shall retain information regarding data, information, and documentation for person
served encounter data specified in 42 CFR §§438.604, 438.606, 438.608, and 438.610 (42
C.F.R. §438.600(b))for a period of no less than 10 years.
Contractor shall ensure sites keep a record of persons served being treated at that
location.
Contractor shall not knowingly have a relationship with a director, officer or partner of
Contractor, a subcontractor of Contractor, a person with beneficial ownership of five (5) percent
or more of Contractor's equity or a network provider or person with an employment, consulting
or other arrangement with the Contractor for the provision of items and services that are
significant and material to the Contractor's obligations under this Agreement with the following:
(A)An individual or entity that is debarred, suspended, or otherwise excluded from
participating in procurement activities under the Federal Acquisition Regulation or
from participating in non-procurement activities under regulations issued under
Executive Order No. 12549 or under guidelines implementing Executive Order No.
12549.
An individual or entity who is an affiliate, as defined in the Federal Acquisition Regulation
at 48 CFR 2, Section 101, of a person described above.
Contractor shall not have a relationship with an individual or entity that is excluded from
participation in any Federal Health Care Program under section 1128 or 1128A of the Act.
(B) ASAM STANDARDS OF CARE
In accordance with Health and Safety Code section 111834.015, DHCS has adopted the
ASAM treatment criteria, or other equivalent evidenced based criteria as the minimum standard
of care for AOD facilities.
For this Agreement and subsequential services, Contractor shall adopt ASAM as the
evidenced based practice standard for LOC.
Contractor shall ensure treatment staff of all SLID treatment programs receive adequate
training in ASAM criteria prior to providing services that includes but is not limited to in person or
e-training modules:
(1) ASAM Module I- Multidimensional Assessment
30
Exhibit E-1
(2) ASAM Module II- From Assessment to Service Planning and Level of Care
(3) ASAM Module III-Introduction to the ASAM Criteria
33. COMPLIANCE PROGRAM, INCLUDING FRAUD PREVENTION AND
OVERPAYMENTS
Contractor shall have in place a compliance program designed to detect and prevent
fraud, waste and abuse, as per 42 C.F.R. § 438.608 (a)(1), that must include:
(A) Written policies, procedures, and standards of conduct that articulate the
organization's commitment to comply with all applicable requirements and standards
under the Agreement, and all applicable federal and state requirements.
(B) A Compliance Office (CO) who is responsible for developing and implementing
policies, procedures, and practices designed to ensure compliance with the
requirements of this Agreement and who reports directly to the CEO and the Board
of Directors.
(C)A Regulatory Compliance Committee on the Board of Directors and at the senior
management level charged with overseeing the organization's compliance program
and its compliance with the requirements under the Agreement.
(D)A system for training and education for the Compliance Officer, the organization's
senior management, and the organization's employees for the federal and state
standards and requirements under the Agreement.
(E) Effective lines of communication between the Compliance Officer and the
organization's employees.
(F) Enforcement of standards through well-publicized disciplinary guidelines.
(G)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,
corrections of such problems promptly and thoroughly to reduce the potential for
recurrence, and ongoing compliance with the requirements under the Agreement.
(H)The requirement for prompt reporting and repayment of any overpayments identified.
Contractor must have administrative and management arrangements or procedures
designed to detect and prevent fraud, waste and abuse of federal or state health care funding.
Contractor must report fraud and abuse information to the County including but not limited to:
(A) Any potential fraud, waste, or abuse as per 42 C.F.R. § 438.608(a), (a)(7),
(B) All overpayments identified or recovered, specifying the overpayment due to
potential fraud as per 42C.F.R. § 438.608(a), (a)(2).
(C) Information about change in a person served's circumstances that may affect the
person served's eligibility including changes in the person served's residence or the
death of the person served as per 42 C.F.R. § 438.608(a)(3).
31
Exhibit E-1
Information about a change in the Contractor's circumstances that may affect the
network provider's eligibility to participate in the managed care program, including the
termination of this Agreement with the Contractor Contractor shall comply with California
Government Code, § 2990 and CCR Title 2, Division 4, Chapter 5, in matters related to the
development, implementation, and maintenance of a nondiscrimination program. Contractor shall
not discriminate against any employee or applicant for employment because sex, race, religion,
color, national origin, ancestry, ethnic group identification, physical disability, mental disability,
medical condition, genetic information, sexual orientation, marital status, age, gender, gender
identity, gender expression, or military or veteran status. Such practices include retirement,
recruitment, advertising, hiring, layoff, termination, upgrading, demotion, transfer, rates of pay or
other forms of compensation, use of facilities, and other terms and conditions of employment.
Contractor agrees to post in conspicuous places, notices available to all employees and applicants
for employment setting forth the provisions of the Equal Opportunity Act (42 USC § 2000(e)) in
conformance with Federal Executive Order No. 11246. Contractor agrees to comply with the
provisions of the Rehabilitation Act of 1973 (29 USC § 794).
Contractor shall implement written policies that provide detailed information about the
False Claims Act ("Act") and other federal and state Laws described in section 1902(a)(68) of
the Act, including information about rights of employees to be protected as whistleblowers.
Contractor shall make prompt referral of any potential fraud, waste or abuse to County
Contractor shall comply with California Government Code, § 2990 and CCR Title 2, Division 4,
Chapter 5, in matters related to the development, implementation, and maintenance of a
nondiscrimination program. Contractor shall not discriminate against any employee or applicant for
employment because sex, race, religion, color, national origin, ancestry, ethnic group identification,
physical disability, mental disability, medical condition, genetic information, sexual orientation,
marital status, age, gender, gender identity, gender expression, or military or veteran status. Such
practices include retirement, recruitment, advertising, hiring, layoff, termination, upgrading,
demotion, transfer, rates of pay or other forms of compensation, use of facilities, and other terms
and conditions of employment. Contractor agrees to post in conspicuous places, notices available
to all employees and applicants for employment setting forth the provisions of the Equal
Opportunity Act (42 USC § 2000(e)) in conformance with Federal Executive Order No. 11246.
Contractor agrees to comply with the provisions of the Rehabilitation Act of 1973 (29 USC § 794).
County may suspend payments to Contractor if DHCS or County determine that there is
a credible allegation of fraud in accordance with 42 C.F.R. § 455.23. (42 C.F.R. § 438.608
(a)($)).
Contractor shall report to the County all identified overpayments and reason for the
overpayment, including overpayments due to potential fraud. Contractor shall return any
overpayments to the County within 60 calendar days after the date on which the overpayment
was identified. (42 C.F.R. § 438.608 (a)(2), (c)(3)).
34. PARITY IN MENTAL HEALTH AND SUBSTANCE USE DISORDER BENEFITS
(A) General Parity Requirement
(1) Contractor shall not impose any financial requirements, Quantitative Treatment
Limitations, or Non-Quantitative Treatment Limitations in any classification of
32
Exhibit E-1
benefit (inpatient, outpatient, emergency care, or prescription drugs) other than
those limitations permitted and outlined in the State-County Contract.
(2) Contractor shall not apply any financial requirement or treatment limitation to
substance use disorder services in any classification of benefit that is more
restrictive than the predominant financial requirement or treatment limitation of
that type applied to substantially all medical/surgical benefits in the same
classification of benefit furnished to person served (whether or not the benefits
are furnished by the Contractor). (42 CFR 438.910(b)(1))
(3) Contractor shall provide substance use disorder services to person served in
every classification in which medical/surgical benefits are provided. (42 CFR
438.910(b)(2))
(B) Quantitative Limitations
(1) Contractor shall not apply any cumulative financial requirement for substance
use disorder services in a classification that accumulates separately from any
established for medical/surgical services in the same classification. (42 CFR
438.910(c)(3))
(C) Non-Quantitative Limitations
(1) Contractor shall not impose a non-quantitative treatment limitation for substance
use disorder benefits in any classification unless, under the policies and
procedures of Contractor as written and in operation, any processes, strategies,
evidentiary standards, or other factors used in applying the non-quantitative
treatment limitation to substance use disorder benefits in the classification are
comparable to, and are applied no more stringently than, the processes,
strategies, evidentiary standards, or other factors used in applying the limitation
for medical/surgical benefits in the classification. (42 CFR §438.910(d))
35. PERSON SERVED INFORMING AND TRANSLATION SERVICES
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 1 557 of the Patient Protection and Affordable
Care Act, the Americans with Disabilities Act, and Section 504 of the Rehabilitation Act.
Contractor shall provide information in a manner and format that is easily understood
and readily accessible to persons served (42 C.F.R. § 438.10(c)(1)). Contractor shall provide all
written materials for persons served in easily understood language, format, and alternative
formats that take into consideration the special needs of persons served in compliance with 42
CF.R. §438.10(d)(6). Contractor shall inform persons served that information is available in
alternate formats and how to access those formats in compliance with 42 C.F.R. §438.10.
Contractor shall provide the required information in this section to each person served
receiving SUD services under this Agreement and upon request.
Contractor shall utilize the County's website that provides the content required in this
section and 42 C.F.R. §438.10 and complies with all the requirements regarding the same set
forth in 42 C.F.R. §438.10.
33
Exhibit E-1
Contractor shall use DHCS/County developed model beneficiary handbook and person
served notices (42 C.F.R. §§ 438.10(c)(4)(ii), 438.62(b)(3)).
Person served's information required in this section may only be provided electronically
by the Contractor if all of the following conditions are met:
(A) The format is readily accessible;
(B) The information is in a location on the Contractor's website that is prominent and
readily accessible;
(C)The information is provided in an electronic form which can be electronically retained
and printed;
(D)The information is consistent with the content and language requirements of this
Agreement;
(E) The person served is informed that the information is available in paper form without
charge upon request and Contractor provides it upon request within five (50 business
days (42 C.F.R. §438.10(c)(6)).
Nondiscrimination Notice Requirements.
(A) Contractor shall post a DHCS-approved nondiscrimination notice that informs
persons served, potential persons served, and the public about nondiscrimination,
protected characteristics, and accessibility requirements and conveys the
Contractor's compliance with the requirements.
(B) 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 persons served, potential
persons served, 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.
(C)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.
(D)The nondiscrimination notice shall include all legally required elements under the
applicable subsections of W&I Code section 14029.91 and Gov. Code section
11135.
(E) The nondiscrimination notice shall include information on how to file a discrimination
grievance directly with the DHCS Office of Civil Rights, 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.
(F) Contractor is not prohibited from posting the nondiscrimination notice in additional
publications and communications
34
Exhibit E-1
Written Materials
(A) Contractor shall provide all written materials for potential persons served and
persons served in a font size no smaller than 12 point (42 C.F.R. §438.10(d)(6)(ii)).
(B) Contractor shall ensure its written materials that are critical to obtaining services are
available in alternative formats, upon request of the person served or potential
person served at no cost.
(C) Contractor shall make its written materials that are critical to obtaining services,
including, at a minimum, provider directories, beneficiary handbook, appeal and
grievance notices, denial and termination notices, and the Contractor's SUD health
education materials, available in the prevalent non-English languages in the County.
(42 C.F.R. § 438.10(d)(3).)
(1) Contractor shall notify persons served, prospective persons served, and
members of the public that written translation is available in prevalent languages
free of cost and how to access those materials. (42 C.F.R. § 438.10(d)(5)(i), (iii);
Welfare & Institutions Code § 14727(a)(1); California Code of Regulations. tit. 9 §
1810.410, subd. (e), para. (4))
(D) Contractor shall make auxiliary aids and services available upon request and free of
charge to each person served. (42 C.F.R. § 438.10(d)(3)- (4).)
(E) Contractor shall make oral interpretation and auxiliary aids, such as Teletypewriter
Telephone/Text Telephone (TTY/TDY) and American Sign Language (ASL),
available and free of charge for any language in compliance with 42 C.F.R. §
438.10(d)(2), (4)-(5).
(F) Taglines for written materials critical to obtaining services must be printed in a
conspicuously visible font size.
Person Served Informing Materials
(A) Each person served must receive and have access to the person served informing
materials upon request by the person served and when first receiving SUD services.
Person served informing materials include but are not limited to:
(1) County DMC-ODS Beneficiary Handbook (BHIN 22-060)
(2) Provider Directory
(3) DMC-ODS Formulary
(4) Advance Health Care Directive Form (required for adult persons served only)
(5) Notice of Language Assistance Services available upon request at no cost to the
person served
(6) Language Taglines
(7) Grievance/Appeal Process and Form
(8) Notice of Privacy Practices
35
Exhibit E-I
(9) EPSDT poster (if serving persons served under the age of 21)
(B) Contractor shall provide each person served with a beneficiary handbook at the time
the person served first accesses services. The beneficiary handbook shall be
provided to persons served within 14 business days after receiving notice of
enrollment.
(C) Contractor shall give each person served notice of any significant change to the
information contained in the beneficiary handbook at least 30 days before the
intended effective date of change as per BHIN 22-060.
(D) Required informing materials must be electronically available on the Contractor's
website and must be physically available at the Contractor agency facility lobby for
person serveds' access.
(E) Informing materials must be made available upon request, at no cost, in alternate
formats (i.e., Braille or Audio) and Auxiliary Aids (i.e., California Relay Service (CRS)
711 and American Sign Language) and must be provided to persons served within
five business days. Large print materials shall be in a minimum 18-point font size.
(F) Informing materials will be considered provided to the person served if Contractor
does one or more of the following:
(1) Mails a printed copy of the information to the person served's mailing address
before the person served first receives a SUD service;
(2) Mails a printed copy of the information upon the person served's request to the
person served's mailing address;
(3) Provides the information by email after obtaining the person served's agreement
to receive the information by email;
(4) Posts the information on the Contractor's website and advises the person served
in paper or electronic form that the information is available on the internet and
includes applicable internet addresses, provided that persons served with
disabilities who cannot access this information online are provided auxiliary aids
and services upon request and at no cost; or,
(5) Provides the information by any other method that can reasonably be expected
to result in the person served receiving that information. If the Contractor
provides informing materials in person, when the person served first receives
SUD services, the date and method of delivery shall be documented in the
person served's file.
Provider Directory
Contractor must follow the County's provider directory policy.
Contractor must make available to persons served, in paper form upon request and
electronic form, specified information about its provider network as per 42 C.F.R. §438.10(h).
The most current provider directory is electronically available on the County website and is
36
Exhibit E-I
updated by the County no later than 30 calendar days after information is received to update
provider information. A paper provider directory must be updated at least monthly.
Any changes to information published in the provider directory must be reported to the
County within two weeks of the change.
Contractor will only need to report changes/updates to the provider directory for each
licensed SUD service provider.
Medication Formulary
(A) Contractor shall make available in electronic or paper form, the following information
about the County's formulary as outlined in 42 C.F.R. § 438.10(i):
(1) Which medications are covered (for both generic and name brand).
(2) What tier each medication resides on.
(B) Contractor shall inform persons served about County's formulary drug lists
availability in a machine-readable file and format on the County's website.
Language Assistance Taglines
(A) Contractor shall post taglines in a conspicuously visible size (no less than 12-point
font), in English and at least the top 18 non-English languages in the State (as
determined by DHCS), persons served, potential persons served, 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.
(B) 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 a location that allows any
visitor to the website to easily locate the information, and in all person served's
information and other information notice, in accordance with federal and state
requirements.
Language Assistance Services
Contractor shall make interpretation services available free of charge and in a timely
manner to each person served. This includes two primary types of language assistance
services: oral and written. Limited English proficiency (LEP) individuals are not required to
accept language services, although a qualified interpreter may be used to assist in
communicating with an LEP individual who has refused language assistance services.
Contractor shall comply with the following oral interpretation requirements:
(A) Contractor shall provide oral interpretation services from a qualified interpreter, on a
24-hour basis, at all key points of contact, at no cost to persons served. Key points of
contact may include medical care settings and non-medical care settings.
(B) Font shall be provided in all languages and is not limited to threshold or
concentration standard languages.
37
Exhibit E-1
(C) Interpretation can take place in-person, through a telephonic interpreter, or internet
or video remote interpreting (VRI) services. However, the Contractor is prohibited
from using remote audio or VRI services that do not comply with federal quality
standards, or relying on unqualified bilingual/multilingual staff, interpreters, or
translators. The Contractor should not solely rely on telephone language lines for
interpreter services. Rather, telephonic interpreter services should supplement face-
to-face interpreter services, which are a more effective means of communication.
(D)An interpreter is a person who renders a message spoken in one language into one
or more languages. An interpreter shall be qualified and have knowledge in both
languages of the relevant terms or concepts particular to the program or activity and
the dialect spoken by the LEP individual. In order to be considered a qualified
interpreter for an LEP individual, the interpreter must:
(1) have demonstrated proficiency in speaking and understanding both English and
the language spoken by the LEP individual;
(2) be able to interpret effectively, accurately, and impartially, both receptively and
expressly, to and from the language spoken by the LEP individual and English,
using any necessary specialized vocabulary, terminology, and phraseology; and
adhere to generally accepted interpreter ethics principles, including person
served confidentiality.
(E) If the Contractor provides a qualified interpreter for an individual with LEP through
remote audio interpreting services, the Contractor shall provide real-time audio over
a dedicated high-speed, wide-bandwidth video connection or wireless connection
that delivers high-quality audio without lags or irregular pauses in communication; a
clear, audible transmission of voices; and adequate training to users of the
technology and other involved individuals so that they may quickly and efficiently set
up and operate the remote interpreting services.
(F) Contractor is prohibited from requiring LEP individuals to provide their own
interpreters, or from relying on bilingual/multilingual staff members who do not meet
the qualifications of a qualified interpreter. Some bilingual/multilingual staff may be
able to communicate effectively in a non-English language when communicating
information directly in that language but may not be competent to interpret in and out
of English. Bilingual/multilingual staff may be used to communicate directly with LEP
individuals only when they have demonstrated that they meet all the qualifications of
a qualified interpreter listed above.
(G)The Contractor is prohibited from relying on an adult or minor child accompanying an
LEP individual to interpret or facilitate communication except when there is an
emergency involving an imminent threat to the safety or welfare of the individual or
the public and a qualified interpreter is not immediately available or the LEP
individual specifically requests that an accompanying adult interpret or facilitate
communication, the accompanying adult agrees to provide that assistance, and
reliance on that accompanying adult for that assistance is appropriate under the
circumstances. Prior to using a family member, friend or, in an emergency only, a
minor child as an interpreter for an LEP individual, the Contractor shall first inform
the individual that they have the right to free interpreter services and second, ensure
38
Exhibit E-1
that the use of such an interpreter will not compromise the effectiveness of services
or violate the LEP individual's confidentiality.
Contractor shall use County's written/translated materials that are critical to obtaining
services, including the provider directory, member handbook, appeal and grievance notices,
and denial and termination notices, available in the prevalent non—English languages. All other
Contractor specific written materials must be made available in the prevalent non-English
languages. Contractor shall ensure that written materials use easily understood language and
format, use a font size no smaller than 12-point, and are made available in alternative formats
upon request of the potential person served or person served at no cost. Written materials shall
include taglines in the prevalent non-English languages in the state, as well as large print,
explaining the availability of written translation or oral interpretation to understand the
information provided and the toll-free and TTY/TDY telephone number of County's
member/customer service unit.
Contractor shall use a qualified translator when translating written content in paper or
electronic form. A qualified translator is a translator who:
(A) Adheres to generally accepted translator ethics principles, including person served
confidentiality;
(B) Has demonstrated proficiency in writing and understanding both written English and
the written non-English language(s) in need of translation; and
(C) Is able to translate effectively, accurately, and impartially to and from such
language(s) and English, using any necessary specialized vocabulary, terminology,
and phraseology.
At a minimum, Contractor shall provide written translations of the person served's
information in the threshold and concentration languages.
36. EFFECTIVE COMMUNICATION WITH INDIVIDUALS WITH DISABILITIES
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. 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. 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), as well as other auxiliary aids and
services that may be appropriate. In determining what types of auxiliary aids and services are
necessary, Contractor shall give "primary consideration" to the individual's request of a
particular auxiliary aid or service. Contractor must also provide auxiliary aids and services to a
family member, friend, or associate of an individual or someone with whom it is appropriate for
the Contractor to communicate (e.g., a disabled spouse of a person served).
Auxiliary aids and services include the following:
39
Exhibit E-1
(A) Qualified interpreters on-site or through Video Remove Interpreting (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 products and systems, text telephones (TTYs),
videophones, captioned telephones, or equally effective telecommunications
devices; videotext displays; accessible information and communication technology;
or other effective telecommunications devices, videotext displays, accessible
information and communication technology; or other effective methods of making
aurally delivered information available to individuals who are dead 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 technology; or other effective methods of making visually
delivered materials available to individuals who are blind or have low vision.
When providing interpretive services, Contractor shall use qualified interpreters to
interpret for an individual with a disability, whether through a remote interpreting service or an
on-site appearance. A qualified interpreter for an individual with a disability is an interpreter who:
(A) adheres to generally accepted interpreter ethics principals, including person served's
confidentiality; and
(B) is able to interpret effectively, accurately, and impartially, both receptively and
expressively, using any necessary specialized vocabulary, terminology, and
phraseology.
For an individual with a disability, qualified interpreters can include, for example, sign
language interpreters, oral transliterators (individuals who represent or spell in the characters of
another alphabet), and cued language transliterators (individuals who represent or spell by
using a small number of handshapes).
If a Contractor provides a qualified interpreter for an individual with a disability through
VRI services, the Contractor shall provide real-time, full-motion video and audio over a
dedicated high-speed, wide-bandwidth video connection or wireless connection that delivers
high-quality video images that do not produce lags, choppy, blurry, or grainy images, or irregular
pauses in communication; a sharply delineated image that is large enough to display the
interpreter's face, arms, hands, and fingers, and the participating individual's face, arms, hands,
and fingers, regardless of body position; a clear, audible transmission of voices; and adequate
training to users of the technology and other involved individuals so that they may quickly and
efficiently set up and operate the VRI. However, VRI will not be effective in all circumstances
and sometimes an on-site interpreter may be required.
Contractor shall not require an individual with a disability to provide their own interpreter.
Contractor is also prohibited from relying on an adult or minor child accompanying an individual
with a disability to interpret or facilitate communication except when:
40
Exhibit E-1
(A) there is an emergency involving an imminent threat to the safety or welfare of the
individual or the public and a qualified interpreter is not immediately available; or,
(B) the individual with a disability specifically requests that an accompanying adult
interpret or facilitate communication, the accompanying adult agrees to provide that
assistance, and reliance on that accompanying adult for that assistance is
appropriate under the circumstances. Prior to using a family member, friend, or, in an
emergency only, a minor child as an interpreter for an individual with a disability,
Contractor shall first inform the individual that they have the right to free interpreter
services and second, ensure that the use of such an interpreter will not compromise
the effectiveness of services or violate the individual's confidentiality. Contractor shall
ensure that the refusal of free interpreter services and the individual's request to use
a family member, friend, or a minor child as an interpreter is documented.
Contractor shall make reasonable modifications to policies, practices, or procedures
when such modifications are necessary to avoid discrimination based on disability.
37. CONTRACTOR SPECIFICATIONS
Contractor shall ensure that professional staff are licensed, registered, enrolled, and/or
approved in accordance with all applicable state and federal laws and regulations. Professional
staff shall abide by the definitions, rules, and requirements for stabilization and rehabilitation
services established by the Department of Health Care Services. Contractor shall ensure that
Physicians receive a minimum of five (5) hours of continuing medical education related to
addiction medicine each year and professional staff(LPHAs) receive a minimum of five (5)
hours of continuing education related to addiction medicine each year. Copies of these
certifications and licenses shall be maintained in staff's personnel files and records shall be
made available to County upon request.
Profession staff is defined as any of the following:
(A) Licensed Practitioners of the Healing Arts (LPHA), including:
(1) Physicians
(2) Nurse Practitioners
(3) Physician Assistants
(4) Registered Nurses
(5) Registered Pharmacists
(6) Licensed Clinical Psychologists
(7) Licensed Professional Clinical Counselors
(8) Licensed Marriage and Family Therapists
(9) Licensed-eligible practitioners registered with the Board of Psychology or
Behavioral Science Board working under the supervision of a licensed clinician
(B) An Alcohol or other drug (AOD) counselor that is either certified or registered by an
organization that is recognized by the Department of Health Care Services and
41
Exhibit E-1
accredited with the National Commission for Certifying Agencies (NCCA), and meets
all California State education, training, and work experience requirements set forth in
the Counselor Certification Regulations, Cal. Code Regs., tit. 9, Div. 4, chapter 8.
(C) Medical Director of a Narcotic Treatment Program who is a licensed physician in the
State of California.
(D)A Medi-Cal Peer Support Specialist with a current State approved Medi-Cal Peer
Support Specialist Certification Program certification and who meet all other
applicable California state requirements, including ongoing education requirements
Contractor shall ensure that non-professional staff receive appropriate onsite orientation
and training prior to performing assigned duties. A professional and/or administrative staff shall
supervise non-professional staff. Professional and non-professional staff are required to have
appropriate experience and any necessary training at the time of hiring. Documentation of
trainings, certifications and licensure shall be contained in personnel files.
38. MEDICAL DIRECTOR REQUIREMENTS
Contractor's Medical Director must, prior to the delivery of services under this Contract,
be enrolled with DHCS under applicable state regulations, screened in accordance with 42 CFR
455.450(a) as a "limited" categorical risk within a year prior to serving as a Medical Director
under this Agreement, and have a signed Medicaid provider agreement with DHCS as required
by 42 CFR 431.107.
Medical Directors shall receive a minimum of five (5) hours of continuing medical
education related to addiction medicine annually.
SUD Medical Director's responsibilities shall, at a minimum, include all of the following:
(A) Ensure that medical care provided by physicians, registered nurse practitioners, and
physician assistants meets the applicable standard of care.
(B) Ensure that physicians do not delegate their duties to non-physician personnel.
(C) Develop and implement written medical policies and standards for the provider.
(D) Ensure that physicians, registered nurse practitioners, and physician assistants
follow the provider's medical policies and standards.
(E) Ensure that the medical decisions made by physicians are not influenced by fiscal
considerations.
(F) Ensure that providers' physicians and LPHAs are adequately trained to perform
diagnosis of substance use disorders for persons served, and determine services are
medically necessary.
(G)Ensure that providers' physicians are adequately trained to perform other physician
duties, as outlined in this section.
The Medical Director Medical Director may delegate their responsibilities to a
physician consistent with the providers' medical policies and standards; however, the
42
Exhibit E-1
Medical Director shall remain responsible for ensuring all delegated duties are
properly performed.
39. MEDICAL NECESSITY
Contractor shall use ASAM criteria to determine medical necessity. Level of Care
determinations are separate and distinct from determining medical necessity.
Contractor shall ensure that all ADULT persons served receive at least one diagnosis
from the Diagnostic and Statistical Manual of Mental Disorders (DSM) Fifth Edition for
Substance-Related and Addictive Disorders. After establishing a diagnosis and documenting the
basis for diagnosis, the American Society of Addiction Medicine (ASAM) Placement Criteria
shall be applied by the diagnosing individual to for placement into the correct level of care.
Non-NTP Contractors shall periodically as directed by County, and at a minimum of
every six (6) months, reassess for continued medical necessity of an ongoing treatment. The
reassessment determination must be documented by the Medical Director, licensed physician
or LPHA as clinically appropriate.
OTP/NTP Contractors shall periodically as directed by County, and at a minimum within
two (2) years from admission and annually thereafter, reassess for continued medical necessity
of an ongoing treatment and determine that those services are still clinically appropriate for that
individual.
For Medical Necessity definition and Assessment and Reassessment timeframes
Contractor shall refer to the Provider Manual.
(A) For individuals under 21 years of age, a service is "medically necessary" or a
"medical necessity" if the service is necessary to correct or ameliorate screened
health conditions. Consistent with federal guidance, services need not be curative or
completely restorative to ameliorate a health condition, including substance misuse
and SUDs. Services that sustain, support, improve, or make more tolerable
substance misuse or an SLID are considered to ameliorate the condition and are
thus covered as EPSDT services. (Section 1396dl(5) of Title 42 of the United States
Code; W&I Code section 14059.5(b)(1)).
(B) Individuals over 21 must receive DMC-ODS services that are medically necessary.
Pursuant to W&I Code section 14059.5(a), 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.
40. ASAM REQUIREMENTS
For the period of July 1, 2023 through December 31, 2024, Contractor shall use
County's American Society of Addiction Medicine (ASAM) criteria assessment tools to
determine placement into the appropriate level of care for all persons served. Contractor shall
ensure that assessment of services for adolescents will follow the ASAM adolescent treatment
criteria.
Beginning January 1, 2025, Contractor shall use either the free ASAM Criteria
Assessment Interview Guide, ASAM CONTINUUM software, or a validated tool subsequently
approved by DHCS and added to the list of approved DMC-ODS ASAM assessment tools.
43
Exhibit E-1
Contractor and Contractor's staff shall comply with obtaining ASAM Criteria training prior
to providing services. Contractor shall ensure that, at minimum, staff conducting assessments
complete ASAM trainings as described in the Staff Training Plan available on the Provider
website. Contractor shall maintain records of ASAM trainings in personnel files and will make
these records available to County upon request.
For persons served 21 and over, a full assessment using the ASAM Criteria shall be
completed within 30 days of the person served's first visit with an LPHA or registered/certified
counselor.
For persons served under 21, or for adults experiencing homelessness, a full
assessment using the ASAM Criteria shall be completed within 60 days of the person served's
first visit with an LPHA or registered/certified counselor.
A full ASAM Criteria assessment is not required to deliver prevention and early
intervention services for persons served under 21; a brief screening ASAM Criteria tool is
sufficient for these services (see below regarding details about ASAM level of care.
If a person served withdraws from treatment prior to completing the ASAM Criteria
assessment or prior to establishing a diagnosis from the DSM for Substance-Related and
Addictive Disorders, and later returns, the time period starts over.
A full ASAM Criteria assessment, or initial provisional referral tool for preliminary level of
care recommendations, shall not be required to begin receiving DMC-ODS services. A full
ASAM assessment does not need to be repeated unless the person served condition changes.
Requirements for ASAM LOC assessments apply to NTP persons served and settings.
A person served's placement and level of care determinations shall ensure that
individuals are able to receive care in the least restrictive level of care that is clinically
appropriate to treat their condition.
41. ADA CONSIDERATIONS
In accordance with the accessibility requirements of section 508 of the Rehabilitation Act
and the Americans with Disabilities Act of 1973, Contractor shall ensure that physical access,
reasonable accommodations, and accessible equipment are available for Medicaid persons
served with physical or mental disabilities.
42. STATE PLAN COUNTIES NTP PERSONS SERVED
OTP Contractors shall ensure that a person served that resides in a county that does not
participate in DMC-ODS does not experience a disruption of NTP services. NTP Contractors
shall provide any medically necessary NTP services covered by the California Medi-Cal State
Plan to persons served that reside in a county that does not participate in DMC-ODS. NTP
Contractors who provide services to an out-of-county person served shall submit claims for
those services to the county in which the person served resides (according to MEDS).
43. DMC CERTIFICATION AND ENROLLMENT
Prior to delivering SUD services Contractor shall obtain any licenses, registrations, DMC
certifications or approval to operate a SUD program or provide a covered service in
44
Exhibit E-I
accordance with applicable laws and regulations. Contractor shall continuously maintain any
licenses, registrations, DMC certifications or approval to operate a SUD program or provide a
covered service in accordance with applicable laws and regulations for the duration of this
Contract. Contractor and any subcontractors shall comply with the following regulations and
guidelines:
(A) Title 21, CFR Part 1300, et seq., Title 42, CFR, Part 8;
(B) Cal. Code Regs., tit. 22, Sections 51490.1(a);
(C) Exhibit A, Attachment I, Article III.XX— Requirements for Services;
(D) Cal. Code Regs., Title 9, Division 4, Chapter 4, Subchapter 1, Sections 10000, et
seq.;
(E) Cal. Code Regs., tit. 22, Div. 3, chapter 3, §§ 51000 et. Seq; and
(F) W&I Code section 1 41 84.100 et seq.
PROVIDER APPLICATION AND VALIDATION FOR ENROLLMENT (PAVE)
Contractor shall ensure that all of its required clinical staff, who are rendering SLID
services to Medi-Cal persons served on behalf of Contractor, are registered through DHCS'
Provider Application and Validation for Enrollment (PAVE) portal, pursuant to DHCS
requirements, the 21st Century Cures Act, and the CMS Medicaid and Children's Health
Insurance Program (CHIP) Managed Care Final Rule.
44. PERINATAL CERTIFICATION REQUIREMENTS
Contractors of perinatal DMC services shall be properly certified to provide these
services and comply with the applicable requirements below:
(A)Perinatal services shall address treatment and recovery issues specific to pregnant
and postpartum women, such as relationships, sexual and physical abuse, and
development of parenting skills.
(B)Perinatal services shall include:
(1) Parent/child habilitative and rehabilitative services (i.e., development of parenting
skills, training in child development, which may include the provision of
cooperative child care pursuant to Health and Safety Code Section 1596.792);
(2) Service access (i.e., provision of or arrangement for transportation to and from
medically necessary treatment);
(3) Education to reduce harmful effects of alcohol and drugs on the parent and fetus
or the parent and infant; and
(4) Coordination of ancillary services (i.e., assistance in accessing and completing
dental services, social services, community services, educational/vocational
training and other services which are medically necessary to prevent risk to fetus
or infant).
45
Exhibit E-I
(C)Medical documentation that substantiates the person served' s pregnancy and the
last day of pregnancy shall be maintained in the person served file.
45. CONTRACTOR DMC CERTIFICATION
DMC certified Contractors shall be subject to continuing certification requirements at
least once every five years. DHCS may allow the Contractor to continue delivering covered
services to person served at a site subject to on-site review by DHCS as part of the
recertification process prior to the date of the on-site review, provided the site is operational, the
certification remains valid, and has all required fire clearances. DHCS shall conduct
unannounced certification and recertification site visits at clinics pursuant to W&I Code, Section
14043.7.
46. DATA, PRIVACY AND SECURITY REQUIREMENTS
CONFIDENTIALITY AND SECURE COMMUNICATIONS
(A) Contractor shall comply with all applicable Federal and State laws and regulations
pertaining to the confidentiality of individually identifiable protected health information
(PHI) or personally identifiable information (PII) including, but not limited to,
requirements of the Health Insurance Portability and Accountability Act (HIPAA), the
Health Information Technology for Economic and Clinical Health (HITECH) Act, the
California Welfare and Institutions Code regarding confidentiality of person served
information and records and all relevant County policies and procedures.
(B) Contractor will comply with all County policies and procedures related to
confidentiality, privacy, and secure communications.
(C) Contractor shall have all employees acknowledge an Oath of Confidentiality
mirroring that of County, including confidentiality and disclosure requirements, as
well as sanctions related to non-compliance.
(D) Contractor shall not use or disclose PHI or PII other than as permitted or required by
law.
ELECTRONIC PRIVACY AND SECURITY
(A) Contractor shall have a secure email system and send any email containing PII or
PHI in a secure and encrypted manner. Contractor's email transmissions shall
display a warning banner stating that data is confidential, systems activities are
monitored and logged for administrative and security purposes, systems use is for
authorized users only, and that users are directed to log off the system if they do not
agree with these requirements.
(B) Contractor shall institute compliant password management policies and procedures,
which shall include but are not limited to procedures for creating, changing, and
safeguarding passwords. Contractor shall establish guidelines for creating
passwords and ensuring that passwords expire and are changed at least once every
90 days.
(C)Any Electronic Health Records (EHRs) maintained by Contractor that contain any
PHI or PII for persons served served through this Agreement shall contain a warning
46
Exhibit E-1
banner regarding the PHI or PII contained within the EHR. Contractor that utilize an
EHR shall maintain all parts of the clinical record that are not stored in the EHR,
including but not limited to the following examples of person served signed
documents: discharge plans, informing materials, and health questionnaire.
(D) Contractor entering data into any County electronic systems shall ensure that staff
are trained to enter and maintain data within this system.
47. ADDITIONAL AGREEMENT RESTRICTIONS
This Agreement is subject to any additional restrictions, limitations, conditions, or
statutes enacted or amended by the federal or state governments, which may affect the
provisions, terms, or funding of this Agreement in any manner.
48. VOLUNTARY TERMINATION OF DMC-ODS SERVICE
Contractor may terminate this Agreement at any time, for any reason, by giving 60 days
written notice to DHCS. Contractor shall be paid for DMC-ODS services provided to persons
served up to the date of termination. Upon termination, the Contractor shall immediately begin
providing DMC services to persons served in accordance with the State Plan.
49. NULLIFICATION OF DMC-ODS SERVICES
The parties agree that failure of County, or Contractor, to comply with W&I Code section
14124.24, 14184.100 et seq., BHIN 21-075, as superseded by BHIN 24-001, the
Intergovernmental Agreement, and any other applicable statutes, regulations or guidance
issued by DHCS, shall be deemed a breach that results in the termination of the State-County
Intergovernmental Agreement for cause. In the event of a breach, the DMC-ODS services shall
terminate. The County shall immediately begin providing DMC services to the person served in
accordance with the State Plan.
50. HATCH ACT
Contractor shall comply with the provisions of the Hatch Act (Title 5 USC, Sections
1501-1508), which limit the political activities of employees whose principal employment
activities are funded in whole or in part with federal funds.
51. NO UNLAWFUL USE OR UNLAWFUL USE MESSAGES REGARDING DRUGS
Contractor agrees that information produced through these funds, and which pertains to
drug and alcohol related programs, shall contain a clearly written statement that there shall be
no unlawful use of drugs or alcohol associated with the program. Additionally, no aspect of a
drug or alcohol related program shall include any message on the responsible use, if the use is
unlawful, of drugs or alcohol (H&S Code section 11999-11999.3). By signing this Agreement,
Contractor agrees that it shall enforce these requirements.
52. NONCOMPLIANCE WITH REPORTING REQUIREMENTS
Contractor agrees that County and DHCS have the right to withhold payment until
Contractor has submitted any required data and reports to DHCS, as identified in the
Intergovernmental Agreement, Exhibit A, Attachment I or as identified in Document 1 F(a),
Reporting Requirement Matrix for Counties.
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Exhibit E-1
53. LIMITATION ON USE OF FUNDS FOR PROMOTION OF LEGALIZATION OF
CONTROLLED SUBSTANCES
None of the funds made available through this Agreement may be used for any activity
that promotes the legalization of any drug or other substance included in Schedule I of Section
202 of the Controlled Substances Act (21 USC 812).
54. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF
1996
If any of the work performed under this Agreement is subject to the HIPAA, Contractor
shall perform the work in compliance with all applicable provisions of HIPAA. As identified in
Exhibit F of the State County Intergovernmental Agreement, DHCS, County and Contractor
shall cooperate to ensure mutual agreement as to those transactions between them, to which
this Provision applies. Refer to Exhibit F for additional information.
(A) Trading Partner Requirements
(1) No Changes: Contractor hereby agrees that for the personal health information
(PHI), it shall not change any definition, data condition or use of a data element
or segment as proscribed in the federal Health and Human Services Transaction
Standard Regulation [45 CFR Part 162915(a)].
(2) No Additions: Contractor hereby agrees that for PHI, it shall not add any data
elements or segments to the maximum data set as proscribed in the HHS
Transaction Standard Regulation [45CFR Part 162.915 (b)].
(3) No Unauthorized Uses: Contractor hereby agrees that for PHI, it shall not use
any code or data elements that are marked `not used" in the in the HHS
Transactions Implementation specification or are not in the HHS Transaction
Standard's implementation specification [45CFR Part 162.915 (c)].
(4) No Changes to Meaning or Intent: Contractor hereby agrees that for PHI, it shall
not change the meaning or intent of the HHS Transaction Standard's
implementation specification [45CFR Part 162.915 (d)].
(B) Concurrence for Test Modifications to HHS Transaction Standards
Contractor agrees and understands that there exists the possibility that DHCS or others
may request an extension from the uses of a standard in the HHS Transaction Standards. If this
occurs, Contractor agrees that it shall participate in such test modifications.
(C)Adequate Testing
Contractor is responsible to adequately test all business rules appropriate to their types
and specialties. If the Contractor is acting as a clearinghouse for enrolled providers, Contractor
has obligations to adequately test all business rules appropriate to each and every provider type
and specialty for which they provide clearinghouse services.
(D) Deficiencies
The Contractor agrees to cure transactions errors or deficiencies identified by DHCS,
and transactions errors or deficiencies identified by an enrolled CONTRACTOR if the County is
48
Exhibit E-1
acting as a clearinghouse for that CONTRACTOR. If the Contractor is a clearinghouse, the
Contractor agrees to properly communicate deficiencies and other pertinent information
regarding electronic transactions to enrolled CONTRACTORS for which they provide
clearinghouse services.
(E) Code Set Retention
Both County and Contractor understand and agree to keep open code sets being
processed or used in this Agreement for a least the current billing period or any appeal period,
whichever is longer.
(F) Data Transmission Loci
Both County and Contractor shall establish and maintain a Data Transmission Log,
which shall record any and all data transmissions taking place between the Parties during the
term of this Agreement. Each Party shall take necessary and reasonable steps to ensure that
such Data Transmission Logs constitute a current, accurate, complete and unaltered record of
any and all Data Transmissions between the Parties, and shall be retained by each Party for no
less than twenty-four (24) months following the date of the Data Transmission. The Data
Transmission Log may be maintained on computer media or other suitable means provided
that, if necessary to do so, the information contained in the Data Transmission Log may be
retrieved in a timely manner and presented in readable form.
55. COUNSELOR CERTIFICATION
Any counselor or registrant providing intake, assessment of need for services, treatment
or recovery planning, individual or group counseling to persons served, patients, or residents in
a DHCS licensed or certified program is required to comply with the requirements in Cal. Code
Regs., tit. 9, div. 4, chapter 8. (Document 3H).
56. CULTURAL AND LINGUISTIC PROFICIENCY
Contractor shall ensure equal access to quality care by diverse populations by adopting
the federal Office of Minority Health Culturally and Linguistically Appropriate Service (CLAS)
national standards (Document 3V) and complying with 42 CFR 438.206(c)(2).
57. TRAFFICKING VICTIMS PROTECTION ACT OF 2000
Contractor shall comply with section 106(g) of the Trafficking Victims Protection Act of
2000 (22 U.S.C. 7104(g)) as amended by section 1702. For full text of the award term, go to:
http://uscode.house.gov/view.xhtml?req=granuleid:USCprelim-title22-
section7104d&num=0&edition=prelim.
Contractor, Contractor's employees, subrecipients, and subrecipients' employees may
not:
(A) Engage in severe forms of trafficking in persons during the period of time that the
award is in effect;
(B) Procure a commercial sex act during the period of time that the award is in effect; or
(C) Use forced labor in the performance of the award or subawards under the award.
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Exhibit E-1
This agreement may be unilaterally terminated, without penalty, if Contractor or a
subrecipient that is a private entity is determined to have violated a prohibition of the
TVPA or has an employee who is determined by the DBH Director or her designee to
have violated a prohibition of the TVPA through conduct that is either associated with
performance under the award or imputed to the Contractor or their subrecipient using
the standards and due process for imputing the conduct of an individual to an
organization that are provided in 2 C.F.R. Part 180, "OMB Guidelines to Agencies on
Government-wide Debarment and Suspension (Non-procurement).
Contractor must inform the DBH Director or her designee immediately of any
information received from any source alleging a violation of a prohibition of the
TVPA.
Contractor must sign a certification annually acknowledging the Trafficking Victims
Protection Act of 2000 requirements (TVPA Certification), attached hereto as
Attachment A, incorporated herein by reference and made part of this Agreement
and must require all employees to complete annual TVPA training.
58. PARTICIPATION IN THE COUNTY BEHAVIORAL HEALTH DIRECTOR'S
ASSOCIATION OF CALIFORNIA
Contractor's administrator or designee shall participate and represent the Contractor in
meetings of the County Behavioral Health Director's Association of California for the purposes
of representing the Contractor in their relationship with DHCS and the County with respect to
policies, standards, and administration for SUD services. The Contractor's administrator or
designee shall attend any special meetings called by the Director of DHCS.
59. ADOLESCENT BEST PRACTICES GUIDELINES
Contractor shall follow the guidelines in Document 1 V, incorporated by this reference,
"Adolescent Best Practices Guidelines," in developing and implementing adolescent treatment
programs funded under this Exhibit, until such time new Adolescent Best Practices Guidelines
are established and adopted. No formal amendment of this Agreement is required for new
guidelines to be incorporated into this Agreement.
60. NONDISCRIMINATION IN EMPLOYMENT AND SERVICES
By signing this Agreement, Contractor certifies that under the laws of the United States
and the State of California, incorporated into this Agreement by reference and made a part
hereof as if set forth in full, Contractor shall not unlawfully discriminate against any person.
61. FEDERAL LAW REQUIREMENTS
Contractor shall comply with the following Federal law requirements:
(A) Title VI of the Civil Rights Act of 1964, section 2000d, as amended, prohibiting
discrimination based on race, color, or national origin in federally funded programs.
(B) Title IX of the Education Amendments of 1972 (regarding education and programs
and activities), if applicable.
50
Exhibit E-1
(C)Title VIII of the Civil Rights Act of 1968 (42 USC 3601 et seq.) prohibiting
discrimination on the basis of race, color, religion, sex, handicap, familial status or
national origin in the sale or rental of housing.
(D)Age Discrimination Act of 1975 (45 CFR Part 90), as amended (42 USC sections
6101 — 6107), which prohibits discrimination on the basis of age.
(E) Age Discrimination in Employment Act (29 CFR Part 1625).
(F) Title I of the Americans with Disabilities Act (29 CFR Part 1630) prohibiting
discrimination against the disabled in employment.
(G)Americans with Disabilities Act (28 CFR Part 35) prohibiting discrimination against
the disabled by public entities.
(H)Title III of the Americans with Disabilities Act (28 CFR Part 36) regarding access.
(1) Rehabilitation Act of 1973, as amended (29 USC section 794), prohibiting
discrimination on the basis of individuals with disabilities.
(J) Executive Order 11246 (42 USC 2000(e) et seq. and 41 CFR Part 60) regarding
nondiscrimination in employment under federal contracts and construction contracts
greater than $10,000 funded by federal financial assistance.
(K) Executive Order 13166 (67 FR 41455) to improve access to federal services for
those with limited English proficiency.
(L) The Drug Abuse Office and Treatment Act of 1972, as amended, relating to
nondiscrimination on the basis of drug abuse.
(M)The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and
Rehabilitation Act of 1970 (P.L.91-616), as amended, relating to nondiscrimination
on the basis of alcohol abuse or alcoholism.
(N) Balanced Budget Act of 1997
(0)Health Insurance Portability and Accountability Act (HIPAA)
62. STATE LAW REQUIREMENTS
Contractor shall comply with the following State law requirements:
(A) Fair Employment and Housing Act (Gov. Code section 12900 et seq.) and the
applicable regulations promulgated thereunder (Cal. Code Regs., tit. 2, Div. 4 §
7285.0 et seq.).
(B) Title 2, Division 3, Article 9.5 of the Gov. Code, commencing with Section 11135.
(C) Cal. Code Regs., tit. 9, div. 4, chapter 8, commencing with §10800.
(D) Cal. Code Regs., tit. 22;
(E) California Welfare and Institutions Code, Division 5;
51
Exhibit E-1
(F) No State or Federal funds shall be used by the Contractor, or its subcontractors, for
sectarian worship, instruction, and/or proselytization. No state funds shall be used by
Contractor, to provide direct, immediate, or substantial support to any religious
activity.
(G)Noncompliance with the requirements of nondiscrimination in services shall
constitute grounds for state to withhold payments under this Agreement or terminate
all, or any type, of funding provided hereunder.
63. INVESTIGATIONS AND CONFIDENTIALITY OF ADMINISTRATIVE ACTIONS
If a DMC provider is under investigation by DHCS or any other state, local or federal law
enforcement agency for fraud or abuse, DHCS may temporarily suspend Contractor from the
DMC program, pursuant to W&I Code, Section 14043.36(a). Information about Contractor's
administrative sanction status is confidential until such time as the action is either completed or
resolved. The DHCS may also issue a Payment Suspension to a provider pursuant to W&I
Code, Section 14107.11 and Code of Federal Regulations, Title 42, section 455.23. The County
is to withhold payments from a DMC provider during the time a Payment Suspension is in effect.
County has executed a Confidentiality Agreement that permits DHCS to communicate with
County concerning Contractor(S) that are subject to administrative sanctions.
64. MEDICATION ASSISTED TREATMENT
DMC-ODS providers, at all levels of care, shall demonstrate that they either directly offer
or have an effective referral mechanism to the most clinically appropriate MAT services for
persons served with SUD diagnoses that are treatable with medications or biological products
(defined as facilitating access to MAT off-site for persons served if not provided on-site.
Providing individuals with the contact information for a treatment program is insufficient). An
appropriate facilitated referral to any Medi-Cal provider rendering MAT to the person served is
compliant whether or not that provider seeks reimbursement.
65. MEDICATIONS
If Contractor provides or stores medications, the Contractor shall store and monitor
medications in compliance with all pertinent statutes and federal standards.
Contractor shall have written policies and procedures regarding the use of prescribed
medications by persons served, and for monitoring and storing of medications.
Prescription and over the counter medications which expire and other bio-hazardous
pharmaceutics including used syringes or medications which are not removed by the person
served upon termination of services shall be disposed of by the program director or a
designated substitute, and one other adult who is not a person served. Both shall sign a record,
to be retained for at least one year.
Contractor shall have at least one program staff on duty at all times trained to
adequately monitor persons served for signs and symptoms of their possible misuse of
prescribed medications adverse medication reactions and related medical complications.
66. EVIDENCE BASED PRACTICES (EBP)
52
Exhibit E-1
Contractor shall implement Motivational Interviewing and at least two EBPs prescribed
by DHCS based on the timeline established by County as outlined in the Provider Manual, and
are delivering these practices to fidelity. The two additional required EBPs may be selected from
the following: Cognitive-Behavioral Therapy, Relapse Prevention, Trauma-Informed Treatment
and Psycho-Education. Three EBPs shall be utilized per service modality. County and DHCS
will monitor the implementation and regular training of EBPs to staff during reviews. Contractor
shall ensure that staff are internally monitored for training, quality of delivery and fidelity of
Evidence Based Practices.
67. MEDI-CAL ELIGIBILITY VERIFICATION
Contractor shall comply with 42 C.F.R. §455.1(a)(2) and BHIN 24-001, to obtain
certification of a person served's eligibility for SUD services under Medi-Cal for each month of
service prior to billing for DMC services for that month. Medi-Cal eligibility verification should be
performed prior to rendering service, in accordance with and as described in the DHCS DMC-
ODS Provider Billing Manual. Options for verifying the eligibility of a Medi-Cal person served are
described in the manual available on the Provider webpage at:
https://www.co.fresno.ca.us/departments/behavioral-health/home/for-providers/contract-
providers/substance-use-disorder-providers
68. POSTSERVICE POSTPAYMENT AND POSTSERVICE PREPAYMENT (PSPP)
DHCS shall conduct Postservice Postpayment and Postservice Prepayment (PSPP)
Utilization Reviews of contracted DMC providers to determine whether the DMC services were
provided in compliance with all regulations and requirements contained in the Intergovernmental
Agreement. DHCS shall issue the PSPP report to the County with a copy to Contractor.
Contractor shall ensure any deficiencies are remediated and County shall attest the deficiencies
have been remediated. Contractor payments are subject to recoupment when a PSPP review
identifies non-compliant services.
All Contractor shall submit a County-approved corrective action plan (CAP) to DHCS
within 60 days of the date of the PSPP report. Contractor(S) that do not comply with the CAP
submittal requirements or fail to implement the approved CAP provisions within the designated
timeline are subject to payment withholding until compliance is determined.
69. CONTROL REQUIREMENTS
Performance under this Agreement is subject to all applicable Federal and State laws,
regulations and standards. Contractor shall establish written policies and procedures
consistent with applicable Federal and State laws, regulations and standards, and shall be held
accountable for audit exceptions taken by the State or County for failure to comply with these
requirements.
These requirements include, but may not be limited to, those set forth in this Agreement,
and:
(A) HSC, Division 10.5, Part 2, commencing with Section 11760;
(B) California Code of Regulations (CCR), Title 9, Division 4, Chapter 8, commencing
with Section 13000;
(C) Government Code Section 16367.8
53
Exhibit E-1
(D)42, CFR, Sections 8.1 through 8.6.
(E) Title 21, CFR, Sections 1301.01 through 1301.93, Department of Justice, Controlled
Substances.
(F) State Administrative Manual (SAM), Chapter 7200 (General Outline of Procedures).
(G)31 U.S.C. sections 7501-7507 (Single Audit Act of 1984; Single Audit Act
Amendments of 1996);
(H)2CFR Part 200 (Uniform Administrative Requirements, Cost Principles, and Audit
Requirements for Federal Awards); and
(1) Contractor shall be familiar with the above requirements and must incorporate these
requirements into written policies and procedures, as applicable.
70. PERFORMANCE REQUIREMENTS
Contractor shall ensure that in planning for the provision of services, the following
barriers to services are considered and addressed:
(A) Lack of educational materials or other resources for the provision of services.
(B) Geographic isolation and transportation needs of persons seeking services or
remoteness of services.
(C) Institutional, cultural, and/or ethnicity barriers.
(D) Language differences.
(E) Lack of service advocates.
(F) Failure to survey or otherwise identify the barriers to service accessibility.
(G)Needs of persons with a disability.
71. PERINATAL PRACTICE GUIDELINES
Contractor shall comply with the perinatal program requirements as outlined in the
Perinatal Practice Guidelines. The Perinatal Practice Guidelines are attached to the
Intergovernmental Agreement as Document 1G, incorporated by reference and available online
at https://www.dhcs.ca.gov/individuals/Pages/Perinatal-Services.aspx. Contractor shall comply
with the current version of these guidelines until new Perinatal Practice Guidelines are
established and adopted. The incorporation of any new Perinatal Practice Guidelines into this
Agreement shall not require a formal amendment.
Contractor shall require that counselors of perinatal DMC services are properly certified
to provide these services and comply with the requirements contained in Title 22, §51341.1,
Services for Pregnant and Postpartum Women and Title 9 commencing with section 10360.
72. COORDINATION AND CONTINUITY OF CARE WITH MANAGED CARE PLANS
Contractor shall coordinate with the Managed Care Plans, Anthem and CaIVIVA Health,
when appropriate, for comprehensive physical and behavioral health screening and
collaborative treatment planning. County shall maintain MOUs with the managed care plans to
54
Exhibit E-1
facility person served care coordination and will monitor Contractors with regard to the
effectiveness of physical health care coordination.
73. FEDERAL CERTIFICATIONS
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND
VOLUNTARY EXCLUSION LOWER TIER COVERED TRANSACTIONS
(A) DBH and Contractor recognize that Federal assistance funds will be used under the
terms of this Agreement. For purposes of this section, DBH will be referred to as the
"prospective recipient".
(B) This certification is required by the regulations implementing Executive Order 12549,
Debarment and Suspension, 29 CFR Part 98, section 98.510, Person serveds'
responsibilities. The regulations were published as Part VII of the May 26, 1988
Federal Register(pages 19160-19211).
(1) The prospective recipient of Federal assistance funds certifies by entering this
Agreement, that neither it nor its principals are presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded from
participation in this transaction by any Federal department or agency.
(2) The prospective recipient of funds agrees by entering into this Agreement, that it
shall not knowingly enter into any lower tier covered transaction with a person who
is debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the Federal
department or agency with which this transaction originated.
(3) Where the prospective recipient of Federal assistance funds is unable to certify to
any of the statements in this certification, such prospective person served shall
attach an explanation to this Agreement.
(4) The Contractor shall provide immediate written notice to DBH if at any time
Contractor learns that its certification in this clause of this Agreement was
erroneous when submitted or has become erroneous by reason of changed
circumstances.
(5) The prospective recipient further agrees that by entering into this Agreement, it will
include a clause identical to this clause of this Agreement, and titled "Certification
Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions", in all lower tier covered transactions and in all solicitations
for lower tier covered transactions.
(6) The certification in this clause of this Agreement is a material representation of fact
upon which reliance was placed by County when this transaction was entered into.
74. SMOKING PROHIBITION REQUIREMENTS
Contractor shall comply with Public Law 103-227, also known as the Pro-Children Act of
1994 (20 USC Section 6081, et seq.), and with California Labor Code Section 6404.5, the
California Smoke-Free Workplace Law.
55
Exhibit E-1
75. ALCOHOL AND/OR DRUG-FREE ENVIRONMENT
Contractor shall provide an alcohol and/or drug-free environment for persons served.
The use of medications for the treatment of SUD, mental illness, or physical conditions, shall be
allowed and controlled as per Contractor's written policies and procedures.
Contractor shall have written policies regarding service delivery for when persons served
experience relapse episodes. These policies shall be supportive of and consistent with the
alcohol and/or drug-free environment of the program.
76. ASSESSMENT OF TOBACCO USE DISORDER
As required by Assembly Bill 541 and BHIN 22-024, all licensed and/or certified SUD
recovery and treatment facilities shall conduct an assessment of tobacco use at the time of
initial intake. The assessment shall include questions recommend in the most recent version of
the DSM under Tobacco Use Disorder, or County's evidence-based guidance, for determining
whether a person served has a tobacco use disorder.
The licensed and/or certified SUD recovery or treatment facility shall do the following:
(A) Provide information to the person served on how continued use of tobacco products
could affect their long-term success in recovery from SUD;
(B) Recommend treatment for tobacco use disorder in the treatment plan; and
(C) Offer either treatment, subject to the limitation of the license or certification issued by
DHCS, or a referral for treatment for tobacco use disorder.
Licensed and/or certified SUD recovery or treatment facilities can also adopt tobacco
free campus policies, to change the social norm of tobacco use, promote wellness, and reduce
exposure to secondhand smoke.
77. NALOXONE REQUIREMENTS
As required by AB 381, Health and Safety Code, § 11834.26, and BHIN 22-025, all
licensed and/or certified SUD recovery or treatment facilities shall comply with the following
requirements:
(A) Maintain, at all times, at least 2 unexpired doses of naloxone, or any other opioid
antagonist medication that is approved by the FDA for the treatment of an opioid
overdose, on the premises of the licensed SUD recovery or treatment facility.
(B) Have at least one staff member, at all times, on the premises who knows the specific
location of the naloxone, or other FDA-approved opioid antagonist medication, and
who has been trained in its administration. Training shall include review of online
resources and the National Harm Reduction Coalition's Opioid Overdose Basics
website to respond effectively to an opioid-associated overdose emergency. Staff
shall certify that they have reviewed and undergone training in opioid overdose
prevention and treatment.
(C)The proof of completion of such training shall be documented in the staff member's
individual personnel file, in accordance with California Code of Regulations (CCR),
Title 9, § 10564(k).
56
Exhibit E-1
(D) Naloxone should be readily available and not stored in locked cabinets or offices.
(E) Providers shall develop written policies and procedures for labeled naloxone,
whether prescribed or received through community distribution, to be kept on person
or at a bedside while in DHCS licensed treatment facilities.
As required by BHIN 23-064, providers of all levels of care providers have the flexibility
to provider or arrange for naloxone to be prescribed and provided to each person served by
leveraging Medi-Cal Rx. DMC-ODS providers authorized to prescribe medication, can prescribe
naloxone to each person served who is under their care and arrange for staff to routinely fill
these prescriptions at a pharmacy on behalf of the members or coordinate delivery from a
pharmacy to the member's location. DMC-ODS providers may also refer patients to pharmacies
that will dispense naloxone directly to the patient.
78. INDEMNIFICATION
The Contractor agrees to indemnify, defend and save harmless the State, its officers,
agents and employees from any and all claims and losses accruing or resulting to any and all
contractors, subcontractors, materialmen, laborers and any other person, firm or corporation
furnishing or supplying work, services, materials or supplies in connection with the performance
of this Agreement and from any and all claims and losses accruing or resulting to any person,
firm or corporation who may be injured or damaged by the Contractor in the performance of this
Agreement.
79. INDEPENDENT CONTRACTOR
The Contractor and the agents and employees of Contractor, in the performance of this
Agreement, shall act in an independent capacity and not as officers or employees or agents of
State of California.
57
PROVIDER REPORTS Fresno County Substance Use Disorder Services
Department of Behavioral Health Exhibit H-1
Report Purpose Submit to Notes Weekly Monthly Annual As
Needed
Tracks level of care determined at sas@
ASAM Level of Care Reports are provided monthly using excel 20th of the
(LOC) screening,assessment,and reassessment fresnocountyca. template provided by DBH. month
and actual LOC referred to. gov
Provides capacity and utilization 5th of
DATAR information on publicly funded SUD DHCS Webpage following
programs. month
24 hours of
occurrence
and
Captures comprehensive client intake, submitted
Smartcare/ DBH
CaIOMS Treatment treatment, and outcomes for statewide CaIOMS includes admission, discharge, and no later than
Data analysis. EHR annual update information. five days
after the
preceding
month
Template provided by DBH.
• Provider shall enter information per
modality. If provider offers multiple
levelsof care within a modality,
Managed care requirement. Used to provider is to use the program ID 1511 of
Monthly Status Report monitor network adequacy standards. sas@ with the lowest LOC(e.g.,for
following
(MSR) Provides status on DMC programs and is fresnocountyca.gov residential,enter info under 3.1 month
used to update provider directory. instead of 3.5).
• Providers are asked to report
departing counselors via MSR as soon
asthey become aware of the
upcoming change.
Provides information on length of waittime sas@ 15th of
Wait List* for admission into a residential program. fresnocountyca.gov Applicable to residential providers only. following
month
03-05-2024
Page 1
PROVIDER REPORTS Fresno County Substance Use Disorder Services
Department of Behavioral Health Exhibit H-1
Report Purpose Submit to Notes Weekly Monthly Annual As
Needed
Ineligible Persons Checks for clinicians' eligibility to provide sas@ 15th of
Screening services based on sanctions or exclusion fresnocountyca.gov Template provided by DBH. current
status. month
Providers are expected to maintain missed
appointment information until such time 15th of
Missed Appointments Collects missed appointment data. N/A that DBH is able to collect that information following
in its Electronic Health Record or other month
database.
DHCS requirement. Collects grievances at mcare@ 15th of
Grievance Log Template provided b DBH following
SUD programs. fresnocountyca.gov p p y month
Network Adequacy Used to monitor network adequacy sas@ Template provided by DBH. Submission Feb 1
Certification Tool (NACT) standards. fresnocountyca.gov dates may be subject to change.
DMC Outpatient Timely data submission on client access to Entered at the time of first contact with the
Smart Care/ DBH As
Timeliness and/or DMC
services, measuring performance against EHR person served. Instructions for completion to needed
Opioid Timeliness established benchmarks for promptness. be provided by DBH.
03-05-2024
Page 2
PROVIDER REPORTS Fresno County Substance Use Disorder Services
Department of Behavioral Health Exhibit H-I
Report Purpose Submit to Notes Weekly Monthly Annual As
Needed
DMC-ODS plans must submit detailed
provider network data for various service
levels using the X12 274 standard.This
includes data for outpatient, intensive
outpatient, residential, and opioid
DMC-ODS 274 Provider treatment programs, covering county- sas@ 25th of
operated and contracted providers.The Template provided by DBH. following
Network Data Reporting fresnocountyca.gov Month
submission must meet specific format and
compliance standards.Additionally, plans
are required to participate in 274
workgroup meetings,with potential
corrective actions or sanctions for non-
compliance
Culturally and
Linguistically Used to monitor adherence to the National
Appropriate Services CLAS Standards which are intended to sas@ late provided b TBD
Template(CLAS)self-assessment advance health equity, improve quality, fresnocountyca.gov p p y DBH.
and CLAS plan and help eliminatehealth care disparities.
Americans with Used to monitor compliance with sas@
Disabilities Act(ADA)Self- legislation that prohibits discrimination fresnocountyca.gov Template provided by DBH TBD
Assessment against people with disabilities.
y•
Identifies costs and charges related to sas@ Due annually; date set b DHCS and DBH TBD
Cost Report y
program. fresnocountyca.gov
03-05-2024
Page 3
PROVIDER REPORTS Fresno County Substance Use Disorder Services
Department of Behavioral Health Exhibit H-1
Report Purpose Submit to Notes Weekly Monthly Annual As
Needed
Electronic copy:
sas@
fresnocountyca.gov
Hard copy:
Mandated questionnaire used to Department of
Risk Assessment determine a provider's risk category Behavioral Health Due annually; date set by DBH TBD
classification. Substance Use
Disorder Services
Attn: Fiscal Analyst
3133 N Millbrook
Ave
Fresno, CA 93703
03-05-2024
Page 4
PROVIDER REPORTS Fresno County Substance Use Disorder Services
Department of Behavioral Health Exhibit H-I
Additional Reports
As
Report Purpose Submit to Notes Weekly Monthly Annual Needed
Surveys assessing provider cultural sas@ Complet
Cultural Competency Template provided by DBH. Completed ov ed semi-
competency,guiding training, and fresnocounty g ca.
Survey policy adjustments semi-annually or as determined by DBH. annually
• Providers are required to
complete an online report of any
Documentation of any incidents incidents that compromise the
LogicManager Incident within treatment settings, Logic Manager health and safety of clients, X
Reporting supporting risk management and Website employees or community
quality improvement efforts members.
• Reports must be submitted within
48 hours of an incident.
• Timeframes vary. Refer to MHSUDS
IN #18-010E:
https://www.dhcs.ca.gov/forms
andpubs/Pages/Behavioral Heal
Notice of Adverse Managed Care requirement. NOABD letters th Information Notice.aspx
Benefit provide information to Medi-Cal persons mcare@fresnocount
Determination served about their appeal rights and other yca.gov Templates provided DBH, X
available at the Provider page:
(NOABD) rights under the Medi-Cal program. https://www.co.fresno.ca.us/depar
tments/behavioralhealth/
home/forproviders/
contractproviders/
substance-use-disorderproviders
03-05-2024
Page 5
Exhibit J-1
Fresno County Department of Behavioral Health
Substance Use Disorder Outpatient Services Rates
Approved Rates by Provider
Rates Effective 7.01.23
Provider Rate Minimum Direct
Provider Type Per Hour Care Percentage
Physicians Assistant $409.38 40%
Nurse Practitioner $453.91 40%
RN $370.76 40%
Pharmacist $436.93 40%
MD $912.79 N/A
Psychologist/Pre-licensed Psychologist $367.09 40%
LPHA(MFT, LCSW, LPCC)/Intern or Waivered LPHA(MFT,
LCSW, LPCC) $237.56 40%
Alcohol and Drug Counselor $197.05 45%
Peer Recovery Specialist $187.66 35%
Fresno County Department of Behavioral Health
Substance Use Disorder Outpatient Services Rates
Supplemental Add-On Service Codes
Rates Effective 7.01.23
Maximum Units
Service Unit That Can Be Rate Per
Billed Unit
1 per allowed
Interactive Complexity 15 minutes per procedure per $16.50
unit provider per
person served
Sign Language or Oral Interpretive Service 15 minutes perVariable $30.00
unit
Revised 05/21/2024 1 of 1