OpenEnrollment-VENDOR-111711
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NOTICE OF OPEN ENROLLMENT (OE)
Home and Community Based Services –
Adult Mental Health Provider Agency
Health and Human Services Commission
OE #: HHS0000075
Enrollment Period Opens: 12/18/2014
Enrollment Period Closes: 08/31/2021
Class/Item: 952/62
TABLE OF CONTENTS
I. INTRODUCTION AND DEFINITIONS 2
A. Introduction 2
B. Definitions 2
II. LIMITATIONS 2
III. FUNDING AND TERM 2
A. Use of Funds 2
B. Funding Obligation 2
C. Term of Contract 2
IV. ELIGIBLE RESPONDENTS 2
A. Eligibility Requirements and Affirmations 2
B. Required Activities for Contractors Receiving an Award under This OE 2
V. PROGRAM INFORMATION 2
A. Scope of Work 2
B. Legal Authority 2
C. Program Requirements 2
D. Method of Payment 2
VI. PROCUREMENT AND ADMINISTRATIVE REQUIREMENTS 2
A. OE Point of Contact 2
B. Submission 2
C. Evaluation Process 2
D. Rejection of Enrollment Applications 2
E. Right to Amend or Withdraw OE 2
F. Authority to Bind SYSTEM AGENCY 2
G. Financial and Administrative Requirements 2
H. Contracting with Subcontractors 2
I. Contract Information 2
VII. APPLICATION INSTRUCTIONS AND CRITERIA FOR ACCEPTANCE 2
VIII. BLANK FORMS AND INSTRUCTIONS 2
FORM A: Face Page 2
FORM B: Open Enrollment Application Checklist 2
FORM C: Contact Person Information Form 2
FORM D: BOARD MEMBER INFORMATION (if applicable) 2
FORM F: PLAN OF HCBS-AMH SERVICE COMPONENT PROVISION 2
FORM G: Subcontracted Providers (if applicable) 2
FORM H: ACCESS TO HOUSING 2
FORM I: Articles of Incorporation and Bylaws, including amendment 2
(if applicable) 2
FORM J: Organizational Overview, Philosophy, or Mission Statement 2
FORM K: Organizational Chart/Structure 2
FORM L: Policies and Procedures 2
FORM M: Job Descriptions 2
FORM N: Proof of General Liability Insurance 2
FORM O: Organization Brochure or Biographical Information 2
IX. APPENDICES 2
APPENDIX A: DSHS ASSURANCES AND CERTIFICATIONS 2
APPENDIX B: GENERAL PROVISIONS 2
APPENDIX C: STANDARDIZED RATES OR APPROVED COSTS 2
I. INTRODUCTION AND DEFINITIONS
A. Introduction
The Health and Human Services Commission (“SYSTEM AGENCY”), Home and Community Based Services-Adult Mental Health (HCBS-AMH) Services Program announces this notice of Open Enrollment (OE) requesting applications to enter into a contingency contract with SYSTEM AGENCY. Respondents are hereby notified that the HCBS-AMH Services Program and all functions associated with the HCBS-AMH Services Program have been transferred by the Department of State Health Services to the SYSTEM AGENCY with all rights, responsibilities and obligations thereto, as provided in Texas Government Code, Section 531.0201.
The contingency contract will require the contractor to provide home and community-based services to adults with a diagnosis of serious mental illness and have a history of at least one of the following additional criteria:
1. Long-term psychiatric hospitalization(s);
2. Frequent arrests and psychiatric crisis;
3. Frequent emergency department (ED) visits and psychiatric crisis.
The contingency contract will provide an array of services, appropriate to each individual’s needs, to enable these individuals to live and experience successful tenure in their community. Contractor will select the population(s) they will serve.
The contingency contract will fund services for individuals enrolled in HCBS-AMH by SYSTEM AGENCY. Aside from the HCBS-AMH service, Recovery Management, respondent shall ensure provision of all HCBS-AMH services listed in Service Codes, Descriptions, and Provider Qualifications found in the HCBS-AMH Provider Manual (Manual) and HCBS-AMH Billing Guideline (Billing Guidelines) which are available online at . Respondent shall provide HCBS-AMH services directly or indirectly by establishing and managing a network of external providers (subcontractors).
Respondents shall coordinate with the individual’s recovery manager for the development of the individual’s Individual Recovery Plan (IRP) using a Person-Centered Recovery Planning Process. Clinical need for HCBS-AMH services must be identified on the individual’s HCBS-AMH Uniform Assessment, and the respondent shall be responsible for verification of medical necessity on the individual’s IRP. Services cannot be provided without SYSTEM AGENCY approval of the IRP. If the individual is eligible but does not have an active Medicaid benefit at the time of enrollment, the HCBS-AMH contractor shall work diligently to access Medicaid benefits for the individual.
The enrollment period begins December 18, 2014 and will remain open through August 31, 2020. Respondents deemed qualified to provide services shall be awarded a Contingency Contract which shall be effective on the day of execution through 8/31/2022. SYSTEM AGENCY may, at its sole discretion, extend the closing date of this OE. As stated in Sec. II, SYSTEM AGENCY may also, at its sole discretion, withdraw this OE before the stated date the enrollment period ends.
Eligible HCBS-AMH respondents will be enrolled in accordance with HCBS-AMH eligibility requirements.
This OE is not limited to this source of funding if other sources become available for this Project.
This OE contains standardized requirements that all respondents must meet to be considered for contracts under this OE. Each respondent is solely responsible for the preparation and submission of an enrollment application in accordance with instructions contained in the OE.
SYSTEM AGENCY recommends Respondents seek technical assistance in completing this OE and HCBS-AMH program implementation support via The University of Texas Health Science Center- San Antonio (UTHSCSA). For more details on the specific assistance available, email Dr. Matt Brown at brownma@uthscsa.edu.
Dr. Matt Brown is a subject matter expert on the HCBS-AMH OE document and process, and can provide comprehensive, no-cost technical assistance to OE Respondents. Dr. Matt Brown and UTHSCSA are prepared to assist Respondents with completing all aspects of the OE.
Respondents that are unsuccessful in three attempts to submit a complete and acceptable application will be restricted from reapplying for 365 days from the date of the last rejected application.
READ ALL MATERIALS BEFORE COMPLETING THIS OE.
B. Definitions
Standard Definitions
Appendix – Additional information and/or forms that are available in the back of this solicitation document.
Budget – A financial schedule documented in the contract that describes how funds will be used and/or describes the basis for reimbursement for the provision of contracted services. Types of budget may include categorical (line item), fee for service, or lump sum payable upon receipt of a product or deliverable.
Budget Period – The duration of the budget (stated in the number of months the contract will reflect from begin date to end date of the term of the contract). Each renewal will have its own budget period.
Center for Medicare and Medicaid Services – The Federal agency within the United States Department of Health and Human Services that administers the Medicare program and works collaboratively with state governments to administer Medicaid.
Contingency Contract – Also called a “contract” in this OE, a written agreement referring to promises or agreements for which the law establishes enforceable duties and remedies between a minimum of two parties and which is contingent on one or more factors. A SYSTEM AGENCY contract is assembled using a core contract (base), one or more program attachments, and other required exhibits (general provisions, etc.).
Contract Term – The period of time during which the contract or program attachment will be effective from execution date to end, or renewal date. The contract term may or may not be the same as the budget period.
Cost Reimbursement- A payment mechanism in which funds are provided to carry out approved contract activities. Reimbursement is based on actual allowable costs incurred that comply with contractual requirements.
Debarment – An exclusion from contracting or subcontracting with state agencies on the basis of cause set forth in Title 34, Texas Administrative Code Chapter 20, Subchapter C, §20.105 et seq.
Deliverables – Goods or services contracted for delivery or performance.
Due Date – Established deadline for submission of a document or deliverable.
Effective Date – The date the contract term is effective.
Entity- A person, business, organization, or LLC that submits a response to solicitation. For purposes of this document, “entity” is intended to include such phrases as “offeror”, “respondent”, “bidder”, “responder”, or other similar terminology employed by SYSTEM AGENCY to describe the person, business, organization or LLC that responds to a solicitation.
Fee for Service – Payment mechanism for services that are reimbursed on an agreed rate per unit of service. Rates are available through SYSTEM AGENCY’s website at
Fully Executed – When a contract is signed by each of the parties to form a legal binding contractual relationship. No costs chargeable to the proposed contract will be reimbursed before the contract is fully executed.
Individual Recovery Plan – A written, individualized plan, developed in consultation with the individual and legally authorized representative, if applicable, which identifies the necessary HCBS to be provided to the individual and also serves as the treatment plan or recovery plan.
Medicaid Management Information System – Automated management and control system for Medicaid payments.
Procurement and Contracting Services (PCS) – The division within the SYSTEM AGENCY that provides direction and support of purchasing, contracting and HUB services. PCS oversees, coordinates, and assists the Program with procurement needs, issues open enrollments and competitive procurements. PCS maintains the official contract file from procurement to contract closeout.
Program – Depending upon the context, either a coordinated group of activities carried out by SYSTEM AGENCY, as authorized by State or Federal law, for a specific purpose (“program”) or SYSTEM AGENCY staff located in a program, region, or hospital that identify and request procurement needs (“Program”). The Program partners with PCS on procurements.
Program Attachment – An attachment to the core contract that provides details for a particular statement of work to be performed under the contract such as services to be delivered, performance measures or deliverables, funding, and reporting requirements. There may be multiple program attachments associated with a core contract. A program attachment is typically for a one-year term, with a contracting cycle made up of several one-year program attachment renewals. Program attachment is sometimes called a contract attachment.
Project – All work to be performed as a result of a contract or solicitation.
Provider of Last Resort – An entity that is the only willing and qualified entity in a geographic area that the individual chooses to provide the service.
Recovery Manager – A person providing the HCBS-AMH recovery management service. Recovery management services assist individuals in gaining access to needed Medicaid state plan and HCBS-AMH services, as well as medical, social, educational, and other resources. Recovery Managers are responsible for monitoring the provision of services included in the Individual Recovery Plan (IRP) to ensure that the individual’s needs, preferences, health and welfare are promoted.
Respondent – A person or entity that submits a response to a solicitation. For purposes of this document, “respondent” is intended to include such phrases as “offeror”, “respondent”, “bidder”, “responder”, or other similar terminology employed by SYSTEM AGENCY to describe the person or entity that responds to a solicitation.
Scope of Work – A description of the services and/or goods, if any, for each service type, to be obtained as a result of this solicitation.
Service Area – The geographical area that a Respondent will serve which is the same as a Local Mental Health Authority’s service area.
Solicitation – The process of notifying prospective contractors of an opportunity to provide goods or services to the state (e.g., OE).
Special Provisions – Amendments or revisions to the General Provisions for a funded program activity; which are usually customized for the Program’s requirements and contain provisions specific to the program attachment.
Statement of Work – The description of services and/or goods to be delivered by the SYSTEM AGENCY contractor specifying the type, level and quality of service, that directly relate to program objectives.
Subcontract – A written agreement between the SYSTEM AGENCY contractor and a third party to provide all or a specified part of the services, goods, work, and materials required in the original contract. The contractor remains entirely responsible to SYSTEM AGENCY for performance of all requirements of the contract with SYSTEM AGENCY. The contractor must closely monitor the subcontractor’s performance. Subcontracting can be done only when expressly allowed in the program attachment.
Supplant (verb) – To replace or substitute one source of funding for another source of funding. A recipient of contract funds under an OE must not use the funds to pay any costs that the recipient is already obligated to pay. If a contractor, prior to responding to an OE, had committed to provide funding for activities defined in the contract’s statement of work (i.e., as represented in the OE Budget Summary), then the contractor must provide the amount of funding previously committed in addition to the amount requested under the OE.
Taxpayer Identification Number (TIN) – Eleven-digit identification number used by the Internal Revenue Service (IRS) in the administration of tax laws. It is issued either by the Social Security Administration or by the IRS.
Unit Rate – Payment mechanism for services that are reimbursed at a set rate per unit of service; for example, treatment services at a prescribed rate per hour. Also known as fee-for-service. Rates are available through SYSTEM AGENCY’s website at .
Vendor – A type of contractor or subcontractor that provides services, and goods, if any, that assist in, but are not the primary means of, carrying out the SYSTEM AGENCY-funded program. Under a vendor contract, the vendor will have few if any administrative requirements. (For example, a vendor might be required only to submit a summary report of services delivered and an invoice.) A vendor generally will deliver services to SYSTEM AGENCY-funded clients in the same manner the vendor would deliver those services to its non-SYSTEM AGENCY-funded clients.
A vendor contractor generally has most of the following characteristics: a) provides goods and services within normal business operations, b) provides similar goods and
services to many different purchasers, c) operates in a competitive environment, d) is not subject to compliance requirements of the Federal or State program, e) provides goods and services that are ancillary to the operation of the program. Note: Characteristics a, b, c, and d do not apply to vendor contractors that are universities.
Vendor Identification Number (Vendor ID No.) – Fourteen-digit number needed for any entity, whether vendor or sub-recipient, to contract with the State of Texas and which must be set up with the State Comptroller’s Office. It consists of a ten-digit identification number (IRS number, state agency number, or social security number) + check digit + 3 digit mail code. The Vendor ID No. includes all the numbers in the TINs (defined above), including a three digit mail code for a total of 14-digits.
Work Plan - A plan that describes how services will be delivered to the eligible population and includes specifics such as what types of clients will be served, who will be responsible for the work, timelines for completion of activities, and how services will be evaluated when complete. To be an enforceable part of the contract, details from the work plan must be approved by SYSTEM AGENCY and incorporated in the contract.
HCBS-AMH Definitions
HCBS-AMH program definitions can be found in the HCBS-AMH Provider Manual, available online at .
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II. LIMITATIONS
Issuance of this OE in no way constitutes a commitment by SYSTEM AGENCY or the State of Texas to execute a contract or to pay any costs incurred by any Respondent who may submit an enrollment application.
The resulting contingency contract will be subject to the availability of State and Federal funds and the need for HCBS-AMH services. Contingency contracts awarded under this OE and any anticipated contract renewals are contingent upon the continued availability of funding. SYSTEM AGENCY reserves the right to alter, amend or withdraw this OE at any time prior to the execution of a contingency contract. If a contingency contract has been fully executed and this OE is altered, amended, or withdrawn, SYSTEM AGENCY and contractor’s obligations and rights will be determined in accordance with the provisions of the contract.
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III. FUNDING AND TERM
A. Use of Funds
Contingency contracts will be awarded for the purpose specifically defined in this OE. SYSTEM AGENCY will review applications in the order in which they are received. The Medicaid rates will be the payment methodology for services provided by a contractor under this contingency contract.
SYSTEM AGENCY, at its sole discretion, may adjust the funding amount of a Program Attachment based on performance measures, outcome measures, waitlist, and/or other criteria determined by SYSTEM AGENCY, and contingent on availability of funds allocated for the adjustments SYSTEM AGENCY may implement an alternative reimbursement methodology using the rates set forth herein (or using the rates that exist at the time a contract is executed). This alternative methodology may include the use of a case rate based on expected lengths of stay.
SYSTEM AGENCY does not guarantee a minimum amount to be paid to a contractor pursuant to a contingency contract awarded through this OE.
B. Funding Obligation
This Contract is contingent upon the availability of funding. If funds become unavailable through lack of appropriations, budget cuts, transfer of funds between programs or Health and Human Services Agencies, amendment of the Appropriations Act, Health and Human Services Agency consolidation, or any other disruptions of current appropriated funding for this Contract, SYSTEM AGENCY may restrict, reduce or terminate funding under this Contract. Notice of any restriction or reduction shall include instructions and detailed information on how SYSTEM AGENCY shall fund the services and/or goods to be procured with the restricted or reduced funds.
C. Term of Contract
Contingency contracts awarded under this OE will be effective on the date of execution through August 31, 2022.
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IV. ELIGIBLE RESPONDENTS
A. Eligibility Requirements and Affirmations
Eligible respondents include organizations established as a legal entity under state statutes and have the authority to do business in Texas. Eligible respondents must comply with the criteria listed below.
1. Respondent must meet the following:
a. Have at least 2 years of experience working with individuals with serious mental illness as an organizational entity; or
b. Currently is a provider of a HCBS Waiver program.
2. Prior to receiving referrals for the provision of HCBS-AMH services, Respondent must be authorized as an active Medicaid Provider.
3. Respondent must be established as an appropriate legal entity as described in the paragraph above, under state statutes and must have the authority and be in good standing to do business in Texas and to conduct the activities described in the OE.
4. Respondent must have an encrypted e-mail extension that is exclusively associated with the respondent’s organization and have capacity to assign employees an e-mail address with the exclusive e-mail extension.
5. Respondent must have a Texas address. A post office box may be used when the enrollment application is submitted, but the respondent must conduct business at a physical location in the service area or within 30 miles of an adjacent service area. This physical location must be zoned to conduct business, be compliant with property agreements, and be obtained prior to the site review as well as prior to date the contract is awarded. If respondent’s business address is their home respondent shall attach proof that the building is approved to be zoned for business or if leased that the building owner approves the space to be used for business purposes.
6. Respondent shall provide SYSTEM AGENCY, upon request, with the personnel files of any or all HCBS-AMH staff (including administration, owners and board members) prior to the commencement of HCBS-AMH services and at the request of SYSTEM AGENCY. Personnel files shall include:
a. Credentialing for employees and subcontractors (including verification of licensure, qualifications, training requirements, certification records; and
b. Federal Criminal Background Check and fingerprints and;
c. Registry Clearances to include but not limited to Nurse Aid Registry and Employee Misconduct Registry
7. Respondent and all administrative staff shall complete HCSB-AMH Pre-application modules located at the following website: prior to completion of the OE application. Respondents shall submit Pre-application certificates with the OE application to verify completion of all HCBS-AMH Pre-application modules.
8. Respondent must be in good standing with the U.S. Internal Revenue Service.
9. Respondent is ineligible to apply for funds under this OE if currently debarred, suspended, or otherwise excluded or ineligible for participation in Federal or State assistance programs.
10. Respondent’s staff members, including the executive director, must not serve as voting members on their employer’s governing board.
11. In compliance with Comptroller of Public Accounts and Texas Procurement and Support Services rules, a name search will be conducted using the websites listed in this section prior to the development of a contract.
12. A respondent is not considered eligible to contract with SYSTEM AGENCY if a name match is found on any of the following lists:
a. The System for Award Management (SAM) is an official U.S. Government system that consolidated the capabilities of CCR/Fed Reg, ORCA and EPLS. Search the federal excluded list at the following website: and
Texas Comptroller of Public Accounts (CPA) Debarment List located at
.
13. Please refer to the Manual located at for guidance on how topics below shall meet the minimum standards. Respondent must have established organizational policies and procedures. Topics include, but are not limited to the following:
a. Confidentiality and retention of client records and progress notes;
b. Provision of services / coordination of care (including routine and emergency appointment availability, and assurance that all HCBS-AMH services will be available to individuals in each service area. This includes notification of SYSTEM AGENCY when HCBS-AMH service is unavailable for any period of time);
c. Quality management plan;
d. Utilization management;
e. Determination of respondent’s capacity to serve individuals;
f. Notification to SYSTEM AGENCY of respondent’s capacity to serve individuals;
g. Housing and placement policies and procedures (monitoring and tracking placement, expansion of community housing relationship plan, and other procedures identified on Form H);
h. Compliance with 1915(i) federal regulations, including settings requirements for provider owned and operating settings;
i. Managing Conflicts of Interest if applying for both Open Enrollment Applications: Provider Agency Agreement and Recovery Management Agreement (include organizational chart that clearly defines separation between Recovery Manager and Provider functions, audit process for managing conflicts of interest, employee training and attestation that no conflict of interest exists, reporting of conflicts of interest to SYSTEM AGENCY such as a change in administrative structure, billing practice and invoice submission).
j. Personnel recordkeeping / management;
k. Critical incident reporting;
l. Personnel and client safety (behavior management, restraint, suicide precaution/prevention); (Including but not limited to: TAC Title 25, Part 1, CH-415 Rules 415.259-415.273)
m. Personnel credentialing and training (including verification of licensure, qualifications, training requirements, and certification records for employees and subcontractors);
n. Medication safety;
o. Process to submit reports and billing invoices to SYSTEM AGENCY (including verification of the individual’s Medicaid for a billing period);
p. Medicaid fair hearing;
q. Consumer rights and grievances;
r. Reporting abuse, neglect, and exploitation;
s. Critical incidents;
t. Transfer of individuals to another HCBS-AMH provider; and
u. Discharge of individuals from HCBS-AMH.
14. Respondent must affirm audit and financial statements are complete and accurate, and demonstrate financial solvency or sufficient cash balances to operate for a minimum of two months.
15. Respondent must affirm they have not violated federal law in connection with any contract awarded by the federal government for relief, recovery or reconstruction efforts as a result of Hurricanes Katrina or Rita or any other disaster occurring after September 25, 2005, in accordance with Texas Government Code §§2155.006 and 2261.053.
16. Respondent affirm they will comply with Human Resources Code, Section 48.253, requiring a provider to:
a. Cooperate completely with an investigation of alleged abuse, neglect, or exploitation conducted by the Department of Family and Protective Services.
b. Provide complete access to the Department of Family and Protective Services during an investigation to:
i. All sites owned, operated, or controlled by the provider; and
ii. Clients and client records.
17. Respondents who are local mental health authorities shall affirm they and their subcontractors will comply with the Texas Administrative Code, Chapter 414, Subchapter L. This includes, but is not limited to:
a. Amending contracts to ensure contractors’ compliance with this subchapter.
b. Implementing policies and procedures addressing disciplinary and other action in confirmed cases of abuse, neglect, and exploitation involving employees and agents, in accordance with Section 414.557.
c. Ensuring that a Client Abuse and Neglect Reporting form (AN-1-A) is completed within 14 calendar days of the receipt of the investigative report from the Department of Family and Protective Services or a decision made after review or appeal using the CANRS Definitions and the CANRS Classifications, when the perpetrator or alleged perpetrator is an employee or agent of the local mental health authority, community center, or contractor, or if the perpetrator is unknown.
d. Ensuring, within one working day after completion of the AN-1-A form, that:
i. The information contained in the completed AN-1-A form is entered into the Client Abuse and Neglect Reporting System (CANRS); or
ii. If access to CANRS is unavailable, a copy of the completed AN-1-A form is forwarded for data entry to the Office of Consumer Services and Rights Protection–Ombudsman, P.O. Box 12668, Austin, TX 78711-2668.
18. Respondent must affirm a contract or Provider Agreement has not been suspended or terminated, license has not been surrendered, or license has not been suspended or revoked by any local, state or federal department or agency or non-profit entity.
19. Respondent must affirm all pending or threatened litigation has been disclosed to SYSTEM AGENCY.
20. Respondent must affirm identification to SYSTEM AGENCY of any related party transactions involving parties that may perform part of the work under the Provider Agreement.
21. Respondent must affirm identification to SYSTEM AGENCY whether any person who has an ownership, controlling or vested interest in the organization to include but not limited to an employee, subcontractor, volunteer, or intern has pending criminal charges, is monitored by community supervision (probation or parole) has received deferred adjudication or has been convicted of a criminal offense in accordance with 25 TAC §414, Subchapter K.
22. Respondent must affirm they have a history of compliance with the laws relating to the respondent’s business operations and the affected services and whether the respondent is currently in compliance;
23. All respondents must have general liability insurance at a minimum of $3Million aggregate (Form N)
24. All documents submitted must be numbered in numerical sequence in the lower right corner. Any additions to the original submission may be added, but the application must be renumbered to ensure the final packet is sequentially numbered and the entire packet resubmitted.
25. If a contingency contract has been fully executed and the Respondent requests to contract to serve additional service region(s) or additional target population(s), Respondent will comply with expansion practices as outlined in the Manual and complete the following:
a. Updated Form-A-Face Page
b. Updated Form-C-Contact Person Information
c. Updated Form G-Organizational Chart
d. Updated Form-J-Proof of General Liability Insurance
e. Updated Form-K-Organizational Brochure or Biographical Information
f. Updated electronic Policy and Procedure Manual from the Respondent to reflect the additional proposed service region(s), target population(s), or programmatic changes due to expansion.
g. Provide addresses to physical locations within the requested expansion service region(s).
i. On site reviews of Respondent offices and residential setting in requested service region(s) designated for individuals enrolled in HCBS-AMH will be conducted at the discretion of SYSTEM AGENCY. Onsite reviews for additional service regions are subject
to the terms identified in Section VI.C.4.
Minimum eligibility requirements for direct service providers of HCBS-AMH services are set forth in the Manual.
B. Required Activities for Contractors Receiving an Award under This OE
1. Respondent must directly or indirectly, through subcontractor, provide the following HCBS-AMH services. Services shall be delivered according to the individual’s IRP approved by SYSTEM AGENCY. Respondent must provide at a minimum one of the services demarcated by (*) directly. A minimum of one directly provided service shall not also be provided through a subcontractor.
a. Adaptive Aids;
b. Host Home/Companion Care;
c. Supported Home Living*;
d. Assisted Living*;
e. Supervised Living*;
f. Community Psychiatric Supports and Treatment*;
g. Employment Assistance;
h. Home Delivered Meals;
i. Minor Home Modifications;
j. Nursing*;
k. Peer Support;
l. HCBS-AMH Psychosocial Rehabilitation*;
m. Respite Care;
n. Substance Use Disorder;
o. Transition Assistance Services;
p. Transportation; and
q. Flexible Funds.
2. Respondent may provide HCBS-AMH services by entering into and managing subcontracts with external providers (subcontractors). Respondent compliance with this requirement may be verified through SYSTEM AGENCY’s respondent review process, annual reviews, encounter data submission, and individual recovery plans.
3. When indicated on an approved IRP, Respondent shall provide allowable services to individuals prior to discharge from the state hospital unless provision of services is not permitted by the state hospital. Prior to execution of the provider agreement, Respondent shall indicate to SYSTEM AGENCY which state hospitals they will be unable to serve due to geographic limitations.
4. Respondent, at own expense, shall conduct an annual Federal Criminal History Background check with fingerprints and Abuse Registry checks for all individuals and subcontractors involved in the administration and provision of HCBS-AMH services to include but not limited to employees, volunteers and interns;
5. Respondent shall comply with the HCBS-AMH Provider Manual ().
6. Respondent shall abide by applicable federal and state laws, regulations, and rules relating to activities listed above.
7. Respondent shall have an e-mail extension that is exclusively associated with the respondent’s organization and have capacity to assign employees and subcontractors an e-mail address with the exclusive e-mail extension.
8. Respondent shall have knowledge of or experience in helping to obtain housing for individuals with mental health and/or substance use issues.
9. Respondent shall have and maintain HIPAA compliant encrypted email to provide SYSTEM AGENCY with reporting data that includes HIPAA-related information.
10. Respondent shall provide SYSTEM AGENCY, upon request, with the personnel files of any or all HCBS-AMH staff (including administration, owners and board members) prior to the commencement of HCBS-AMH services and at the request of SYSTEM AGENCY. Personnel files shall include:
a. Credentialing (including verification of licensure, qualifications, training requirements, and certification records for employees, subcontractors, volunteers, and interns) and
b. Federal Criminal Background Check with Fingerprints and Abuse Registry Clearances.
11. Respondent shall receive approval from SYSTEM AGENCY on their determined capacity to serve prior to the provision of HCBS-AMH services.
12. Respondent shall affirm they have a history of compliance with the laws relating to the respondent’s business operations and the affected services and whether the respondent is currently in compliance.
13. Respondent shall maintain appropriate documentation of all HCBS-AMH services in the format prescribed by SYSTEM AGENCY. Information shall be collected, maintained, and reported by Respondent in accordance with the following specifications:
a. All reports shall be submitted to SYSTEM AGENCY within the time frame and formats, and including subject matter, specified in this Provider Agreement.
b. Respondent shall respond within five working days to requests for ad hoc reports by SYSTEM AGENCY.
c. Respondent shall submit all Critical Incident Reporting Forms within 72 hours of notification of an incident report, in accordance with SYSTEM AGENCY policy.
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V. PROGRAM INFORMATION
A. Scope of Work
HCBS-AMH services are designed to support long term recovery from mental illness. Recovery is not a “cure,” but an on-going process through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Dimensions of personal recovery include better managing one’s physical and mental well-being, attaining stable and safe housing, engaging in meaningful daily life activities to achieve personal goals, forging and cultivating relationships with others in the community, developing a positive sense of identity, and regaining belief in one’s self. HCBS-AMH services are not time-limited, but available to the individual for as long as they need them.
Upon enrollment into the HCBS-AMH program, the vendor shall provide all services, directly or indirectly, as specified on the individual’s IRP. The HCBS-AMH respondent shall provide all HCBS-AMH services directly or indirectly by establishing and managing a network of Subcontractors. Services shall be provided in accordance with the service codes, descriptions, HCBS-AMH Billing Guidelines and provider qualifications defined in the Manual, to individuals participating in the HCBS-AMH Program.
The HCBS-AMH respondent shall comply with terms and conditions set forth in the most current version of the Manual. The HCBS-AMH respondent shall ensure services are provided in compliance with the HCBS-AMH Provider Manual regardless of whether the HCBS-AMH respondent provides services directly or through subcontractors. In addition to covering general topics, the Manual contains detailed information specific to HCBS-AMH respondent’s roles and responsibilities.
The HCBS-AMH respondent shall comply with SYSTEM AGENCY and other Texas licensing standards and certification principles and requirements to the extent applicable to the services provided under the contract type identified in this contract.
Individuals enrolled in the HCBS-AMH program will select an approved Contractor to provide HCBS-AMH Services during the enrollment process. Services shall be provided in accordance with applicable state laws, rules and HCBS-AMH requirements. These include but are not limited to applicable federal laws and regulations, including the Code of Federal Regulations (CFR), Title 42, Parts 440, 441, 455 and 456; 45 CFR, Parts 46, 80, 84, 90 and 91; 25 Texas Administrative Code (TAC), Chapter 414, and applicable subchapters of 1 TAC, Chapter 355; the laws, rules and regulations cited in the various sections of the Manual; and any rules or regulations that are promulgated subsequent to the execution of a contingency contract and that are applicable to HCBS-AMH respondent’s provision of services under this OE. Contractor shall be compensated for HCBS-AMH Provider Agreement services based on the Medicaid rates of services established by SYSTEM AGENCY. This OE is not limited to this source of funding if other sources become available for this project.
The HCBS-AMH respondent shall verify all direct service staff, including employees and subcontractors are credentialed and HCBS-AMH service qualifications are satisfied as outlined in the Manual. This includes participation in required training components as identified in the Manual. The HCBS-AMH Provider shall maintain proof of this credentialing and training and allow SYSTEM AGENCY to review subcontractors’ credentialing files upon request.
B. Legal Authority
SYSTEM AGENCY is authorized to enter into contracts through Texas Health and Safety Code Chapter 12. The HCBS-AMH Program is administered under Social Security Act §1915(i). SYSTEM AGENCY, as the Texas Medicaid Agency, delegated administration of the HCBS-AMH Program to SYSTEM AGENCY as authorized by Texas Government Code §531.0055.
C. Program Requirements
Contractors are required to conduct Project activities in accordance with federal and state laws prohibiting discrimination. Guidance for adhering to non-discrimination requirements can be found on the SYSTEM AGENCY Civil Rights Office website at:
Upon request, a contractor must provide the SYSTEM AGENCY Civil Rights Office with copies of all the contractor’s civil rights policies and procedures. Contractors must notify SYSTEM AGENCY’s Civil Rights Office of any civil rights complaints received relating to performance under the contract no more than 10 calendar days after receipt of the complaint. Notice must be directed to:
HHSC Civil Rights Office
701 W. 51st Street, Mail Code W206
Austin, TX 78751
Phone Toll Free (888) 388-6332
Phone: (512) 438-4313TTY
Toll Free (877) 432-7232
Fax: (512) 438-5885
Contractors shall ensure that its policies do not have the effect of excluding or limiting the participation of persons in the contractor’s programs, benefits or activities on the basis of national origin, and must take reasonable steps to provide services and information, both orally and in writing, in appropriate languages other than English, in order to ensure that persons with limited English proficiency are effectively informed and can have meaningful access to programs, benefits, and activities.
Contractors must comply with Executive Order 13279, and its implementing regulations at 45 CFR, Part 87, or 7 CFR, Part 16, which provide that any organization that participates in programs funded by direct financial assistance from the U.S. Dept. of Agriculture or U.S. Dept. of Health and Human Services must not, in providing services,
discriminate against a program beneficiary or prospective program beneficiary on the basis of religion or religious belief.
Contractors are required to conduct Project activities in accordance with the most recent DSHS Standards for Public Health Clinic Services.
Contractors may obtain a copy of the most recent DSHS Standards for Public Health Clinic Services which is posted at the following:
.
SYSTEM AGENCY reserves the right to modify the Statement of Work of the contract and to incorporate Special Provisions into contracts awarded under this OE.
SYSTEM AGENCY reserves the right to perform a Quality Management review at SYSTEM AGENCY’s sole discretion.
D. Method of Payment
When a contingency contract is activated, Contractor shall submit invoices to SYSTEM AGENCY. SYSTEM AGENCY will reimburse HCBS-AMH Contractor for HCBS-AMH services provided on a Medicaid rate structure. Rates are available through SYSTEM AGENCY’s website at .
Reimbursement shall be provided by SYSTEM AGENCY to Contractor in accordance with the provisions stated in the contingency contract. Provider shall request payment using the invoice process described in the Statement of Work of the contract to request reimbursement of the required services/deliverables. Acceptable supporting documentation for services/deliverables shall be included within the invoice.
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VI. PROCUREMENT AND ADMINISTRATIVE REQUIREMENTS
A. OE Point of Contact
For purposes of submitting questions concerning this OE, the only contact is the Mental Health Contract Management Unit unless otherwise delegated by the OE Point of Contact. All communications concerning this OE must be submitted by email to:
OE Point of Contact Email: MHContracts@hhsc.state.tx.us
Ref: OE# HHS0000075
Other employees and representatives of SYSTEM AGENCY are not permitted to answer questions or otherwise discuss the contents of the OE with any respondents or potential respondents or their representatives. Failure to observe this restriction may result in disqualification of this or other subsequent enrollment applications. This restriction does not preclude discussions between affected parties for the purpose of conducting business unrelated to this OE.
Questions will not be answered verbally. Questions must be submitted by email to the OE Point of Contact email above.
Questions and answers will be posted on the HHS Opportunities Page as appropriate. System Agency reserves the right to amend answers prior to the open enrollment closing date.
B. Submission
The completed enrollment application must be submitted to the OE point of contact at the email address specified in Section VI. A. OE Point of Contact will not accept enrollment applications by mail or fax. Form A requires an original signature. Please scan and make it part of email submittal. Within five (5) business days of submittal, OE point of contact will send an email confirming receipt of application. If you do not receive a confirmation email from the OE point of contact, your application email submittal may have technically failed in transmission. If this has occurred, please contact the OE point of contact to determine the technical problem.
C. Evaluation Process
Enrollment applications will be evaluated according to the criteria below. All enrollment applications remain with SYSTEM AGENCY and will not be returned to the respondent.
Enrollment applications are evaluated for eligibility and completeness. The eligibility criteria requirements include the following:
1. The respondent must meet the eligibility criteria and affirmations as outlined in Section IV. Eligible Respondents.
2. Other preliminary screening criteria as needed and appropriate, including:
a. FORM A: Face Page;
b. FORM B: Open Enrollment Application checklist;
c. FORM C: Contact Person Information;
d. FORM D: Board Member Information (if applicable);
e. FORM E: Vendor Information;
f. FORM F: Plan of HCBS-AMH service provision;
g. FORM G: Subcontracted Providers (if applicable);
h. FORM H: Access to Housing;
i. FORM I: Articles of Incorporation and Bylaws, including amendment (if applicable);
j. FORM J: Organizational Overview, Philosophy, or Mission Statement;
k. FORM K: Organizational Chart/Structure;
l. FORM L: Policies and Procedures; and
m. FORM M: Job Descriptions.
n. FORM N: Proof of General Liability Insurance
o. FORM O: Organization Brochure or Biographical Information
3. After screening, OE Point of Contact will delegate direct communications to SYSTEM AGENCY program for other evaluation purposes.
4. The respondent may be subject to an Onsite Review which may include, but is not limited to, the review and verification of:
a. Information submitted as a part of the OE application;
b. Policies and Procedures Manuals or Operational Handbooks to include the following policies and procedures:
i. Confidentiality and retention of client records and progress notes;
ii. Provision of services / coordination of care (including routine and emergency appointment availability, and assurance that all HCBS-AMH services will be available to individuals in each service area. This includes notification of SYSTEM AGENCY when HCBS-AMH service is unavailable for any period of time);
iii. Quality management plan;
iv. Utilization management;
v. Determination of respondent’s capacity to serve individuals;
vi. Housing and placement policies and procedures (monitoring and tracking placement, expansion of community housing relationship plan, and other procedures identified on Form H);
vii. Compliance with 1915(i) federal regulations, including settings requirements for provider owned and operating settings;
viii. Managing Conflicts of Interest;
ix. Personnel recordkeeping / management;
x. Critical incident reporting;
xi. Personnel and client safety (behavior management, restraint, suicide precaution/prevention);
xii. Personnel credentialing and training (including verification of licensure, qualifications, training requirements, and certification records for employees and subcontractors);
xiii. Medication safety;
xiv. Process to submit reports and billing invoices to SYSTEM AGENCY (including verification of the individual’s Medicaid for a billing period);
xv. Medicaid fair hearing;
xvi. Consumer rights and grievances;
xvii. Reporting abuse, neglect, and exploitation;
xviii. Critical incidents;
xix. Transfer of individuals to another HCBS-AMH provider; and
xx. Discharge of individuals from HCBS-AMH.
c. Entity licensing, credentialing, and personnel files including review of any subcontractor agreements;
d. Organizational or facility environment;
e. Client record keeping practices, by reviewing an existing client record;
f. Qualifications (education, experience, licensure, certification, training requirements, and registration) of all individuals to provide services as described in the Manual. This includes professional standards and regulations, including malpractice or liability insurance for professional staff; and
g. Ability to provide all HCBS-AMH services directly or indirectly through subcontractors.
On site reviews of Respondent offices and residential setting in requested service region(s) designated for individuals enrolled in HCBS-AMH will be conducted at the discretion of SYSTEM AGENCY. Respondents will provide addresses to physical locations within the requested service region(s).
In conducting the evaluation process, SYSTEM AGENCY at its sole discretion may give respondents an opportunity to submit missing information or correct identified areas of noncompliance within a specified period of time. This evaluation is strictly ‘pass’ or ‘fail’ as this is not a competitive process and enrollment applications are not scored.
The provisions of the contract will be determined at the sole discretion of SYSTEM AGENCY staff.
D. Rejection of Enrollment Applications
1. SYSTEM AGENCY reserves the right to reject any or all enrollment applications and is not liable for any costs incurred by the respondent in the development or submission of the enrollment application.
2. Any attempt by an employee, officer, or agent of the respondent to influence the outcome of SYSTEM AGENCY’s review through contact with any Commissioner or staff member of SYSTEM AGENCY or other Texas Health and Human Services agency will result in rejection of the enrollment application.
3. Any material misrepresentation in an enrollment application submitted to SYSTEM AGENCY will result in rejection of the enrollment application.
4. Enrollment applications may be rejected for failure to meet respondent eligibility criteria or inability to perform required activities.
5. If a Respondent wishes to re-apply for the Open Enrollment after receiving a
rejection letter:
a. Respondent is not permitted to re-apply for 6 months from the date of the rejection letter;
b. Respondent must correct the item(s) identified in the rejection letter prior to re-applying: and
c. Respondent must complete and submit a new OE PA Application.
E. Right to Amend or Withdraw OE
SYSTEM AGENCY reserves the rights to alter, amend, or modify any provisions of this OE or to withdraw this OE at any time prior to the execution of a contract if it is in the best interest of SYSTEM AGENCY and the State of Texas. The decision of SYSTEM AGENCY is administratively final. Amendment or notice of withdrawal of the OE will be posted to the HHS Opportunities Page.
F. Authority to Bind SYSTEM AGENCY
For the purposes of this OE, the Commissioner of SYSTEM AGENCY, Assistant Commissioner, Chief Financial Officer or Chief Operating Officer, or the employee designated through commissioner’s directive relating to line of authority (CD-2005.02) to act in place of one of those employees is granted the signature responsibility of that employee are the only individuals who may legally commit SYSTEM AGENCY to the expenditure of public funds under the contract. No costs chargeable to the proposed contract will be reimbursed before the contract is fully executed.
G. Financial and Administrative Requirements
General Provisions:
1. All contractors under this OE must comply with the FY2015 DSHS Core Vendor General Provisions. The FY2015 DSHS Core Vendor General Provisions are located at: .
2. Respondent is not required to return the General Provisions or DSHS Assurances and Certifications with their enrollment application. By signing the Form A: Face Page, respondent is agreeing to abide by the referenced General Provisions and DSHS Assurances and Certifications.
H. Contracting with Subcontractors
If the selected respondent enters into contracts with subcontractors, the documents must be in writing and must comply with the requirements specified in articles of the General Provisions posted on the HHS Opportunities Page in conjunction with this OE
The selected contractor may enter into contracts with subcontractors unless restricted or otherwise prohibited in a specific Program Attachment(s). The contractor is responsible to SYSTEM AGENCY for the performance of any subcontractor.
I. Contract Information
Any exceptions to the requirements in the OE sought by the respondent will be specifically detailed in writing by the respondent in the proposal submitted to SYSTEM AGENCY for consideration. SYSTEM AGENCY will accept or reject each proposed exception. SYSTEM AGENCY reserves the right to adjust the funding allocation to contractors pursuant to the terms of the contract.
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VII. APPLICATION INSTRUCTIONS AND CRITERIA FOR ACCEPTANCE
The following application documents are required:
FORM A: Face Page;
FORM B: Open Enrollment Application Checklist;
FORM C: Contact Person Information;
FORM D: Board Member Information (if applicable);
FORM E: Vendor Information Form;
FORM F: Plan of HCBS-AMH Service Component Provision;
FORM G: Subcontracted Providers (if applicable);
FORM H: Access to Housing;
FORM I: Articles of Incorporation and Bylaws, including amendment (if applicable);
FORM J: Organizational Overview, Philosophy, or Mission Statement;
FORM K: Organizational Chart/Structure;
FORM L: Policies and Procedures; and
FORM M: Job Descriptions
FORM N: Proof of General Liability Insurance
FORM O: Organization Brochure or Biographical Information
Respondent shall submit all documents required in this OE. An application must be complete to be considered. SYSTEM AGENCY expressly reserves the right to review and analyze the documentation submitted and determine the respondent’s eligibility for open enrollment.
Respondent Signature. Application must contain original signatures on all forms requiring signatures.
Application Preparation and Assembly. Submit an application. A complete application consists of responses to all required forms and information listed on FORM B, Open Enrollment Application Checklist.
Place the Application Face Page (FORM A) at the front of the application packet followed by Open Enrollment Application Checklist (FORM B). Beginning with the Application Face Page, number every page of the application consecutively, in the lower right corner.
Applications must be submitted according to Section VI. A. OE Point of Contact.
Upon receipt, the application will be screened for completeness and accuracy and evaluated. Respondents that meet the eligibility requirements and submit the signed and completed forms included in this OE will pass the evaluation.
After the application and contract is signed by both parties, an executed copy of the contract will be mailed to the respondent.
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VIII. BLANK FORMS AND INSTRUCTIONS
Contractor must abide by the requirements contained in the following exhibits, as applicable:
FORM A: Face Page;
FORM B: Open Enrollment Application Checklist;
FORM C: Contact Person Information;
FORM D: Board Member Information (if applicable);
FORM E: Vendor Information Form;
FORM F: Plan of HCBS-AMH Service Component Provision;
FORM G: Subcontracted Providers (if applicable);
FORM H: Access to Housing;
FORM I: Articles of Incorporation and Bylaws, including amendment (if applicable);
FORM J: Organizational Overview, Philosophy, or Mission Statement;
FORM K: Organizational Chart/Structure;
FORM L: Policies and Procedures; and
FORM M: Job Descriptions
FORM N: Proof of General Liability Insurance
FORM O: Organization Brochure or Biographical Information
APPENDIX A: DSHS Assurances and Certifications
APPENDIX B: General Provisions
APPENDIX C: Standardized Rates or Approved Costs
APPENDIX D: LMHA Service Regions by County
FORM A: Face Page
Health and Human Services Commission
Home and Community-Based Services-Adult Mental Health (HCBS-AMH) Program
Open Enrollment Application OE# HHS0000075
|RESPONDENT INFORMATION |
|1) LEGAL BUSINESS | |
|NAME: | |
|2) Business MAILING Address Information (include mailing address, street, city, county, state and 9-digit zip code): | | |
| | |
| | |
| | |
| | |
|3) PAYEE Mailing Address, including 9-digit zip code (if different from above): | | |
| | |
| | |
| | |
| | |
|4) Federal Tax ID No. (9-digit), State of Texas Comptroller Vendor ID No. (14-digit) or if an | |
|individual, Social Security Number (9-digit) : | |
|*The vendor acknowledges, understands and agrees that the vendor's choice to use a social security number as the vendor identification number for the |
|contract, may result in the social security number being made public via state open records requests. |
|5) Population(s) Served (check all that apply): |
|Long-Term Hospitalization Jail Diversion Emergency Department (ED) Diversion |
|6) Medicaid Provider Number (7 digits), if applicable: | |
|7) TYPE OF ENTITY (check all that apply): |
| | |City | |Nonprofit Organization* | |Individual |
| | |County | |For Profit Organization* | |FQHC |
| | |Other Political Subdivision | |HUB Certified | |State Controlled Institution of Higher Learning |
| | |State Agency | |Community-Based Organization | |Hospital |
| | |Indian Tribe | |Minority Organization | |Private | |
| | | |
|8) SERVICE REGION(S) TO BE SERVED BY PROJECT (Refer to APPENDIX D: LMHA | |
|Service Regions by County) | |
| | |
|9) LIST THE STREET ADDRESS FOR EACH SERVICE REGION LOCATION or P.O. BOX IF LOCATION IS NOT YET SECURED: |
| |
|10) PROJECT CONTACT PERSON | | |
| Name: | | | | | |
|Phone: | | | | | |
|Fax: | | | | | |
|E-mail: | | | | | |
|The facts affirmed by me in this application are truthful and I warrant that the respondent is in compliance with the assurances and certifications attached |
|in Appendix A, and will provide services in accordance with 25 Texas Administrative Code, §§37.51-37.65. This document has been duly authorized by the |
|governing body of the respondent and I (the person signing below) am authorized to represent the respondent. |
|11) AUTHORIZED REPRESENTATIVE | |12) SIGNATURE OF AUTHORIZED REPRESENTATIVE |
| |Name: | | |
| |Title: | | |
| |Phone: | | |
| |Fax: | | |
| |E-mail: | | |
| | | |13) DATE |
| | | | | |
GENERAL INSTRUCTIONS FOR THE FACE PAGE
This form provides basic information about the respondent and the proposed project with the Health and Human Services Commission (HHSC), including the signature of the authorized representative. It is the cover page of the enrollment application and is required to be completed. Signature affirms that the facts contained in the respondent’s response are truthful and that the respondent is in compliance with the assurances and certifications contained in Appendix A: DSHS Assurances and Certifications and acknowledges that continued compliance is a condition for the award of a contract. Please follow the instructions below to complete the face page form and return with the respondent’s enrollment application.
1) LEGAL NAME - Enter the legal name of the respondent.
2) BUSINESS MAILING ADDRESS INFORMATION - Enter the respondent’s complete street and mailing address, city, county, state, and 9-digit zip code. If respondent’s business address is their home respondent shall attach proof that the building is approved to be zoned for business or if leased that the building owner approves the space to be used for business purposes.
3) PAYEE MAILING ADDRESS - Payee – Entity involved in a contractual relationship with respondent to receive payment for services rendered by respondent and to maintain the accounting records for the contract; i.e., fiscal agent. Enter the PAYEE’s name and mailing address, including 9-digit zip code, if PAYEE is different from the respondent. The PAYEE is the corporation, entity or vendor who will be receiving payments.
4) FEDERAL TAX ID/STATE OF TEXAS COMPTROLLER VENDOR ID/SOCIAL SECURITY NUMBER - Enter the Federal Tax Identification Number (9-digit) or the Vendor Identification Number assigned by the Texas State Comptroller (14-digit). *The vendor acknowledges, understands and agrees that the vendor's choice to use a social security number as the vendor identification number for the contract, may result in the social security number being made public via state open records requests.
5) POPULATION(S) SERVED - Check the appropriate box(s) for the population(s) that you choose to serve.
A) Long-Term Hospitalization: Extended in-patient psychiatric hospitalizations as defined by the HCBS-AMH Provider Manual located at .
B) Jail Diversion: Frequent misdemeanor arrests and psychiatric crisis as defined by the HCBS-AMH Provider Manual located at .
C) Emergency Department (ED) Diversion: Frequent utilization of the ED and psychiatric crisis as defined by the HCBS-AMH Provider Manual located at .
6) Medicaid Provider Number– Enter the 7-digit Medicaid Provider number if currently a Medicaid provider.
7) TYPE OF ENTITY - The type of entity is defined by the Secretary of State and/or the Texas State Comptroller. Check all appropriate boxes that apply.
HUB is defined as a corporation, sole proprietorship, or joint venture formed for the purpose of making a profit in which at least 51% of all classes of the shares of stock or other equitable securities are owned by one or more persons who have been historically underutilized (economically disadvantaged) because of their identification as members of certain groups: Black American, Hispanic American, Asian Pacific American, Native American, and Women. The HUB must be certified by the Texas Building and Procurement Commission or another entity.
MINORITY ORGANIZATION is defined as an organization in which the Board of Directors is made up of 50% racial or ethnic minority members.
If a Non-Profit Corporation or For-Profit Corporation, provide the 10-digit charter number assigned by the Secretary of State.
8) SERVICE REGION SERVED BY PROJECT - Enter the proposed Service Regions(s) served by the project. Refer to the Service Regions List in Appendix D.
9) LIST THE STREET ADDRESS FOR EACH SERVICE REGION – Enter the physical street address (business location) for each service region indicated in line 8. If business location has not yet been secured, list the P.O. Box for each service region. For multiple service areas, the Provider’s business office must be within 30 miles of the adjacent service area. A business address must be listed for each service region selected. If business address is a home respondent shall attach proof that the building is approved to be zoned for business or if leased that the building owner approves the space to be used for business purposes.
10) PROJECT CONTACT PERSON - Enter the name, phone, fax, and e-mail address of the person responsible for the proposed project.
11) AUTHORIZED REPRESENTATIVE - Enter the name, title, phone, fax, and e-mail address of the person authorized to represent the respondent. Check the “Check if change” box if the authorized representative is different from previous submission to HHSC.
12) SIGNATURE OF AUTHORIZED REPRESENTATIVE - The person authorized to represent the respondent must sign in this blank.
13) DATE - Enter the date the authorized representative signed this form.
FORM B: Open Enrollment Application Checklist
Each Enrollment Application Must Contain the Following Completed Items:
|Document |Check (√), if |
| |included |
|FORM A: HHSC Face Page – Signature Required | |
|FORM B: Open Enrollment Application Checklist | |
|FORM C: Contact Person Information Form | |
|FORM D: Board Member Information (if applicable) | |
|FORM E: Vendor Information Form – Signature Required | |
|FORM F: Plan of HCBS-AMH Service Component Provision | |
|FORM G: Subcontracted Providers (if applicable) | |
|FORM H: Access to Housing | |
|FORM I: Articles of Incorporation and Bylaws, including amendment (if applicable) | |
|FORM J: Organizational Overview, Philosophy, or Mission Statement | |
|FORM K: Organizational Chart/Structure | |
|FORM L: Policies and Procedures | |
|FORM M: Job Descriptions | |
|FORM N: Proof of General Liability Insurance | |
|FORM O: Organization Brochure or Biographical Information | |
FORM C: Contact Person Information Form
| | |
|Legal Name of Respondent: | |
This form provides information about the appropriate contacts in the respondent’s organization in addition to those on the FACE PAGE. If any of the following information changes during the term of the contract, please send written notification to the Contract Management Unit.
| |
|Contact: | | |Mailing Address (incl. street, city, county, state, & zip): |
|Title: | | | | |
|Phone: | |Ext. | | | |
|Fax: | | | | |
|E-mail: | | | | |
| |
| |
|Contact: | | |Mailing Address (incl. street, city, county, state, & zip): |
|Title: | | | | |
|Phone: | |Ext. | | | |
|Fax: | | | | |
|E-mail: | | | | |
| |
| |
|Contact: | | |Mailing Address (incl. street, city, county, state, & zip): |
|Title: | | | | |
|Phone: | |Ext. | | | |
|Fax: | | | | |
|E-mail: | | | | |
| |
| |
|Contact: | | |Mailing Address (incl. street, city, county, state, & zip): |
|Title: | | | | |
|Phone: | |Ext. | | | |
|Fax: | | | | |
|E-mail: | | | | |
| |
| |
|Contact: | | |Mailing Address (incl. street, city, county, state, & zip): |
|Title: | | | | |
|Phone: | |Ext. | | | |
|Fax: | | | | |
|E-mail: | | | | |
| |
| |
| |
FORM D: BOARD MEMBER INFORMATION (if applicable)
|Organization Name: | |
Provide the information below for each Board Member. Additional lines may be added if needed.
|Name: | |
|Board Officer Title: | |
|Board Term: | |
|Home Address: | |
|City, State, ZIP: | |
|Personal Email Address: | |
|Home Telephone #s: | | | |
|Fax Number: | | | |
|Name: | |
|Board Officer Title: | |
|Board Term: | |
|Home Address: | |
|City, State, ZIP: | |
|Personal Email Address: | |
|Home Telephone #s: | | | |
|Fax Number: | | | |
|Name: | |
|Board Officer Title: | |
|Board Term: | |
|Home Address: | |
|City, State, ZIP: | |
|Personal Email Address: | |
|Home Telephone #s: | | | |
|Fax Number: | | | |
| Instructions: This form must be completed and submitted with each new contract, amendment, renewal, and/or extension. |
|(Please type or print information.) |
|FORM E: Vendor Information Form |
|SECTION 1: Contractor’s General Information |
|Legal Contractor’s Name: | |
|Legal Doing Business As (DBA) Name: | |
|Physical Address: | |
|Remit To (Payment) Address: | |
|Enter one of the following: |Texas Identification Number (TIN): |
| | |
| |Federal Employer Identification Number (FEIN): |
| | |
| |Social Security Number (SSN): |
|Select the Legal Status: | For-profit Entity | Non-profit Entity |
|Select the Business Structure: | Corporation | Joint Venture | Partnership* |
| | Limited (Liability) Company | Limited (Liability) Partnership | Sole Proprietorship |
| | Governmental Entity (must specify): |
| | Other (must specify): |
| |* If Partnership, must provide SSN or TIN for minimum of two partners |
| |Partner Name: | |TIN or SSN: | |
| |Partner Name: | |TIN or SSN: | |
|If applicable, enter |State of Incorporation: |Texas Charter Number: |Name of Parent Entity: |
|appropriate information: | | | |
| | | | |
| SECTION 2: Contractor’s Contact Information |
|Person Who Will Sign the Contract |Point of Contact for Contract |
|Name: | |Name: | |
|Title: | |Title: | |
|Mailing Address: | |Mailing Address: | |
|Telephone: | |Telephone: | |
|Fax: | |Fax: | |
|E-mail: | |E-mail: | |
| SECTION 3: Contractor’s Authorized Signature (or HHSC Contract Manager) |
|Printed Name |Signature |Date |Phone Number |
| | | | |
| SECTION 4: PCS Contract Administration Office Use Only |
|Contractor to Receive Payment: | No | Yes |
|Contract Number: | |
FORM F: PLAN OF HCBS-AMH SERVICE COMPONENT PROVISION
Please indicate below how HCBS-AMH services will be provided, directly or through a subcontract arrangement, by checking the appropriate box. All services need to be checked in one of the three options presented.
Note: Respondent shall ensure provision of all HCBS-AMH services listed below and as approved by HHSC identified on the HCBS-AMH respondent’s Individual Recovery Plan (IRP).
|HCBS-AMH Service |Provided Directly |Subcontracted |Both |
|Adaptive Aids | | | |
|Host Home/Companion Care | | | |
|Supported Living* | | | |
|Assisted Living* | | | |
|Supervised Living* | | | |
|Community Psychiatric Supports and Treatment* | | | |
|Employment Assistance | | | |
|Home Delivered Meals | | | |
|Minor Home Modification | | | |
|Nursing* | | | |
|Peer Support | | | |
|HCBS-AMH Psychosocial Rehabilitation* | | | |
|Respite Care | | | |
|Substance Use Disorder | | | |
|Transition Assistance Services | | | |
|Transportation | | | |
|Flexible Funds | | | |
* Respondent must provide one of the services demarcated by (*) directly. At least one of the “provided directly” services shall not be subcontracted.
FORM G: Subcontracted Providers (if applicable)
Provide the information below for each Subcontracted Provider. Additional lines may be added if needed.
|Subcontractor Name: |
|Street: |
|City: |
|ZIP: |
|Phone include Area Code: |
|Service(s) Provided: |
|Qualifications: |
|Subcontractor Name: |
|Street: |
|City: |
|ZIP: |
|Phone include Area Code: |
|Service(s) Provided: |
|Qualifications: |
|Subcontractor Name: |
|Street: |
|City: |
|ZIP: |
|Phone include Area Code: |
|Service(s) Provided: |
|Qualifications: |
FORM H: ACCESS TO HOUSING
Respondent shall demonstrate relationship with housing providers or ability to build relationship with housing providers in the community. Respondent shall attest of proof of relationships/or capacity to build by completion of this form.
|Do you have provider owned and operated units that meet the HCBS Settings Code of Federal Regulations (CFR) as outlined at |
| |
| |
|Yes No |
|Do you have access to housing or partnerships with housing providers that meet HCBS Settings CFR requirements that are not owned or operated |
|by the provider agency? |
| |
|Yes No |
| |
| |
|What federally subsidized Housing and Urban Development (HUD) project based rental assistance is currently available in the service area you |
|are applying for? |
| |
| |
| |
|What state subsidized Texas Department of Housing and Community Affairs (TDHCA) Tennant Based Rental Assistance (TBRA) or Project Base Rental |
|Assistance (PBRA) or Tax Credit properties are currently available in the service area you are applying for? |
| |
| |
| |
|Do you have procedures in place to support and track successful housing including: |
|The appeals process for the Local Housing Authority; |
|Clear steps to take to advocate for individuals denied housing; and |
|Resources you can access to house individual with a criminal background and substance use history. |
| |
|Yes No |
91 – Revised 8/31/2011
FORM I: Articles of Incorporation and Bylaws, including amendment
(if applicable)
Respondent shall use this space to submit proof of Articles of Incorporation and Bylaws, including amendment. Respond must use a 12 point font with double spaced lines. Additional pages may be added as needed.
FORM J: Organizational Overview, Philosophy, or Mission Statement
Respondent shall use this space to submit proof of organizational overview, philosophy, or mission statement. Respond must use a 12 point font with double spaced lines. Additional pages may be added as needed, up to a maximum of 5 pages.
FORM K: Organizational Chart/Structure
Respondent shall use this space to submit proof of organizational/chart structure. This organizational/chart structure must clearly support your ability to administratively manage all aspects of the HCBS-AMH Provider Agency. Respond must use a 12 point font with double spaced lines. Additional pages may be added as needed.
FORM L: Policies and Procedures
Respondent shall attach organizational policies and procedures for providing HCBS-AMH services. Please refer to the Provider Manual located at for guidance on how policies and procedures meet the minimum standards. Respond must use a 12 point font with double spaced lines. Additional pages may be added as needed.
FORM M: Job Descriptions
Respondent shall attach job descriptions for both contractor and subcontractor for each HCBS-AMH position with required staff qualifications. Please refer to the Provider Manual located at for guidance on each HCBS-AMH job description. Respond must use a 12 point font with double spaced lines. Additional pages may be added as needed.
FORM N: Proof of General Liability Insurance
Respondent shall use this space to submit proof of general liability insurance.
FORM O: Organization Brochure or Biographical Information
Respondent shall use this space to submit an organizational brochure or biographical information. Additional pages may be added as needed.
IX. APPENDICES
APPENDIX A: DSHS ASSURANCES AND CERTIFICATIONS
Note: Respondents are not required to return the DSHS Assurances and Certifications with their applications. Some of these Assurances and Certifications may not be applicable to your project. If you have questions, contact the contact person named in this Enrollment. These assurances and certifications will remain in effect throughout the project period of this solicitation and the term of any contract between Respondent and DSHS.
As the duly authorized representative of the Respondent, my signature on FORM A: FACE PAGE certifies that the Respondent:
1. Is a legal Respondent legally authorized and in good standing to do business with the State of Texas and has the legal authority to apply for state/federal assistance, and has the institutional, managerial and financial capability and systems (including funds sufficient to pay the non-state/federal share of project costs) to ensure proper planning, management and completion of the project described in this proposal; possesses legal authority to apply for funding; that a resolution, motion or similar action has been duly adopted or passed as an official act of the Respondent’s governing body, authorizing the filing of the proposal including all understandings and assurances contained therein, and directing and authorizing the person identified as the authorized representative of the Respondent to act in connection with the proposal and to provide such additional information as may be required;
2. Under Government Code Section 2155.004, is not ineligible to receive the specified contract and acknowledges that this contract may be terminated and payment withheld if this certification is incorrect. NOTE: Under Government Code Section 2155.004, a Respondent is ineligible to receive an award under this RFP if the bid includes financial participation with the Respondent by a person who received compensation from DSHS to participate in preparing the specification of RFP on which the bid is based;
3. Has a financial system that identifies the source and application of DSHS funds and program income in a unique set of general ledger account numbers, permits preparation of reports required by the contract, permits the tracing of funds expended and program income, allows for the comparison of actual expenditures to budgeted amounts, and maintains accounting records that are supported by verifiable source documents;
4. Will give (and any parent, affiliate, or subsidiary organization, if such a relationship exists, will give) DSHS, HHSC Office of Inspector General, the Texas State Auditor, the Comptroller General of the United States, and if appropriate, the federal government, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives;
5. Will not supplant funds (i.e. use funds from a contract awarded as a result of this RFP to replace or substitute existing funding from other sources that also supports the activities that are the subject of the contract), but rather will use funds from the contract to supplement any existing funds currently available for any such activities;
6. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain;
7. Will ensure that no officer, employee, or member of the Respondent’s governing body or of the Respondent’s contractor will vote or confirm the employment of any person related within the second degree of affinity or the third degree of consanguinity (as defined in Texas Government Code Chapter 573) to any member of the governing body or to any other officer or employee authorized to employ or supervise such person. This prohibition does not prohibit the continued employment of a person who has been continuously employed for a period of two years, or such other period stipulated by local law, prior to the election or appointment of the officer, employee, or governing body member related to such person in the prohibited degree;
8. Has not given, offered to give, nor intends to give, at any time hereafter any economic opportunity, present or future employment, gift, loan, gratuity, special discount, trip, favor, or service to any employee or official of DSHS or HHSC, in connection with this solicitation or procurement; does not have nor will it knowingly acquire any interest that would conflict in any manner with the performance of its obligations under any awarded contract that results from this RFP;
9. Will honor for 90 days after the proposal due date the technical and business terms contained in the proposal;
10. Will initiate the work after receipt of a fully executed contract and will complete it within the contract period;
11. Will not require a client with limited English proficiency to provide or pay for the services of a translator or interpreter;
12. Will identify and document on client records the primary language/dialect of a client who has limited English proficiency and the need for translation or interpretation services;
13. Will make every effort to avoid use of any persons under the age of 18 or any family member or friend of a client as an interpreter for essential communications with clients who have limited English proficiency. However, a family member or friend may be used as an interpreter if this is requested by the client and the use of such a person would not compromise the effectiveness of services or violates the client’s confidentiality, and the client is advised that a free interpreter is available;
14. Will comply with the Uniform Grant Management Act (UGMA), Texas Government Code, Chapter 783, as amended, and the current Uniform Grant Management Standards (UGMS), issued by the Governor's Budget and Planning Office, applicable Office of Management and Budget Federal Circulars, and if applicable the Federal awarding agency Common Rule and U.S. Department of Health and Human Services Grants Policy Statements, which apply as terms and conditions of any resulting contract. A copy of the UGMS manual and federal references available upon request;
15. Will remain current in its payment of franchise tax or is exempt from payment of franchise taxes, if applicable;
16. Will comply, if applicable, with Texas Family Code, § 231.006, regarding Child Support, and certifies that it is not ineligible to receive payment if awarded a contract, and acknowledges that any resulting contract may be terminated and payment may be withheld if this certification is inaccurate;
17. Will comply with the non-discriminatory requirements of Texas Labor Code, Chapter 21, which requires that certain employers not discriminate on the basis of race, color, disability, religion, sex, national origin, or age;
18. Will not charge a fee or profit. A profit and/or fee are considered to be an amount in excess of actual allowable costs that are incurred in conducting an assistance program;
19. Will comply with all applicable requirements of all other state/federal laws, executive orders, regulations, and policies governing this program;
20. In accordance with 2 CFR Part 376 and 180 (parts A-I), as the primary participant, and any of the primary participant’s principals (collectively, participants):
A. are not presently disqualified, debarred, suspended, proposed for debarment, declared ineligible, or excluded from covered transactions by any federal department or agency;
B. have not within a 3-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a private or public (federal, state, or local) transaction or contract under a private or public transaction; violation of federal or state antitrust statutes (including those proscribing price fixing between competitors, allocation of customers between competitors and bid rigging) or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements or false claims, tax evasion, obstruction of justice, receiving stolen property or any other offense indicating a lack of business integrity or business honesty that seriously and directly affects the participant’s present responsibility;
C. are not presently indicted or otherwise criminally or civilly charged by a governmental Respondent (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) of this certification;
D. have not within a 3-year period preceding this proposal/proposal had one or more public transactions (federal, state, or local) terminated for cause or default; and
E. has not (nor has its representative nor any person acting for the representative) (1) violated the antitrust laws codified by Chapter 15, Texas Business & Commercial Code, or the federal antitrust laws; or (2) directly or indirectly communicated the bid to a competitor or other person engaged in the same line of business.
Should the Respondent not be able to provide this certification (by signing the FACE PAGE Form), an explanation should be placed after this form in the proposal response;
The Respondent agrees by submitting this proposal that the Respondent will include, without modification, the certifications in subparagraphs A through E of this paragraph in all lower tier covered transactions (i.e., transactions with sub grantees and/or contractors) and in all solicitations for lower tier covered transactions;
21. Will comply with Title 31, USC §1352, entitled “Limitation on use of appropriated funds to influence certain federal contracting and financial transactions,” which generally prohibits recipients of federal grants and cooperative agreements from using federal (appropriated) funds for lobbying the executive or legislative branches of the federal government in connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires that each person who requests or receives a federal grant or cooperative agreement must disclose lobbying undertaken with non-federal (non-appropriated) funds. These requirements apply to grants and cooperative agreements EXCEEDING $100,000 in total costs (45 CFR Part 93):
A. No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement;
B. If any funds other than federally-appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agent, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the Respondent must complete and submit Standard Form-LLL, “Disclosure of Lobbying Activities,” (SF-LLL) in accordance with its instructions. SF-LLL and continuation sheet are available upon request from the Department of State Health Services; and
C. The language of this certification must be included in the award documents for all sub-awards at all tiers (including subcontracts, sub grants, and contracts under grants, loans and cooperative agreements) and that all sub recipients must certify and disclose accordingly;
This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31 USC §1352. Any person who fails to file the required certification must be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure;
22. Is in good standing with the Internal Revenue Service on any debt owed;
23. Affirms that no person who has an ownership or controlling interest in the organization or who is an agent or managing employee of the organization has been placed on community supervision, received deferred adjudication or been convicted of a criminal offense related to any financial matter, federal or state program or felony sex crime;
24. Is in good standing with all state and/or federal departments or agencies that have a contracting relationship with the Respondent;
25. Will comply with all statutes and standards of general applicability. It is Respondent’s responsibility to review and comply with all applicable statutes, rules, regulations, executive orders and policies. Respondent will carry out the terms of this Contract in a manner that is in compliance with the provisions set forth below. To the extent such provisions are applicable to Respondent; Respondent will comply with the following:
a) The following statutes, rules, regulations and DSHS policies, and any of their subsequent amendments that collectively prohibit discrimination on the basis of race, color, national origin, limited English proficiency, sex, sexual orientation (where applicable), disabilities, age, substance abuse, political belief, or religion: 1) Title VI of the Civil Rights Act of 1964, 42 U.S.C.A. §§∍ 2000d et seq.; 2) Title IX of the Education Amendments of 1972, 20 U.S.C.A. §∍∍§ 1681-1683, and 1685-1686; 3) Section 504 of the Rehabilitation Act of 1973, 29 U.S.C.A. § 794(a); 4) the Americans with Disabilities Act of 1990, 42 U.S.C.A. §§∍ 12101 et seq.; 5) Age Discrimination Act of 1975, 42 U.S.C.A. §∍∍§ 6101-6107: 6) Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970, 42 U.S.C.A. §∍ 290dd (b)(1); 7) 45 CFR Parts 80, 84, 86 and 91 or CFR Part 15; 8) Tex. Lab. Code, ch. 21; 9) Food Stamp Act of 1977 (7 USC §200 et seq); 10) US Department of Labor, Equal Opportunity E.O. 11246, as amended and supplemented; 11) Executive Order 13279 and 45 CFR Part 87 or 7 CFR Part 16 (regarding equal treatment and opportunity for religious organizations; 12) DSHS Policy AA-5018, Non-discrimination Policies and Procedures for DSHS Programs; and13) any other nondiscrimination provision in specific statutes under which application for federal or state assistance is being made, which prohibits exclusion from or limitation of participation in programs, benefits, or activities, or denial of any aid, care, service or other benefit;
b) Drug Abuse Office and Treatment Act of 1972, 21 U.S.C.A. §§ 1101 et seq., relating to drug abuse;
c) Public Health Service Act of 1912, §§∍ 523 and 527, 42 U.S.C.A. §∍ 290dd-2, and 42 C.F.R. pt. 2, relating to confidentiality of alcohol and drug abuse patient records;
d) Title VIII of the Civil Rights Act of 1968, 42 U.S.C.A. §§ 3601 et seq., relating to nondiscrimination in housing;
e) Immigration Reform and Control Act of 1986, 8 U.S.C.A. § 1324a, regarding employment verification;
f) Pro-Children Act of 1994, 20 U.S.C.A. §§ 6081-6084, regarding the non-use of all tobacco products;
g) National Research Service Award Act of 1971, 42 U.S.C.A. §§∍ 289a-1 et seq., and 6601 (P.L. 93-348 and P.L. 103-43), as amended, regarding human subjects involved in research;
h) Hatch Political Activity Act, 5 U.S.C.A. §§∍∍ 7321-26, which limits the political activity of employees whose employment is funded with federal funds;
i) Fair Labor Standards Act, 29 U.S.C.A. §§ 201 et seq., and the Intergovernmental Personnel Act of 1970, 42 U.S.C.A. §§ 4701 et seq., as applicable, concerning minimum wage and maximum hours;
j) Tex. Gov’t Code ch. 469 (Supp. 2004), pertaining to eliminating architectural barriers for persons with disabilities;
k) Texas Workers’ Compensation Act, Tex. Labor Code, chs. 401-406 28 Tex. Admin. Code pt. 2, regarding compensation for employees’ injuries;
l) The Clinical Laboratory Improvement Amendments of 1988, 42 USC § 263a, regarding the regulation and certification of clinical laboratories;
m) The Occupational Safety and Health Administration Regulations on Blood Borne Pathogens, 29 CFR § 1910.1030, or Title 25 Tex. Admin Code ch. 96 regarding safety standards for handling blood borne pathogens;
n) Laboratory Animal Welfare Act of 1966, 7 USC §§ 2131 et seq., pertaining to the treatment of laboratory animals;
o) Environmental standards pursuant to the following: 1) Institution of environmental quality control measures under the National Environmental Policy Act of 1969, 42 USC §§ 4321-4347 and Executive Order 11514 (35 Fed. Reg. 4247), “Protection and Enhancement of Environmental Quality;” 2) Notification of violating facilities pursuant to Executive Order 11738 (40 CFR Part 32), “Providing for Administration of the Clean Air Act and the Federal Water Pollution Control Act with respect to Federal Contracts, Grants, or Loans;” 3) Protection of wetlands pursuant to Executive Order 11990, 42 Fed. Reg. 26961; 4) Evaluation of flood hazards in floodplains in accordance with Executive Order 11988, 42 Fed. Reg. 26951 and, if applicable, flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234); 5) Assurance of project consistency with the approved State Management program developed under the Coastal Zone Management Act of 1972, 16 USC §§ 1451 et seq; 6) Conformity of federal actions to state clean air implementation plans under the Clean Air Act of 1955, as amended, 42 USC §§ 7401 et seq.; 7) Protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, 42 USC §§ 300f-300j; 8) Protection of endangered species under the Endangered Species Act of 1973, 16 USC §§ 1531 et seq.; 9) Federal Water Pollution Control Act, 33 USC §1251 et seq.; 10) Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§ 1271 et seq.) related to protecting certain rivers system; and 11) Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§ 4801 et seq.) prohibiting the use of lead-based paint in residential construction or rehabilitation;
p) Intergovernmental Personnel Act of 1970 (42 USC §§4278-4763 regarding personnel merit systems for programs specified in Appendix A of the federal Office of Program Management’s Standards for a Merit System of Personnel Administration (5 C.F.R. Part 900, Subpart F);
q) Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646), relating to fair treatment of persons displaced or whose property is acquired as a result of Federal or federally-assisted programs;
r) Davis-Bacon Act (40 U.S.C. §§ 276a to 276a-7), the Copeland Act (40 U.S.C. § 276c and 18 U.S.C. § 874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. §§ 327-333), regarding labor standards for federally-assisted construction sub-agreements;
s) Assist DSHS in complying the National Historic Preservation Act of 1966, §106 (16 U.S.C. § 470), Executive Order 11593, and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§ 469a-1 et seq.) regarding historic property;
t) Financial and compliance audits in accordance with Single Audit Act Amendments of 1996 and OMB Circular No. A-133, “Audits of States, Local Governments, and Non-Profit Organizations;” and
u) Requirements of any other applicable state and federal statutes, executive orders, regulations, rules, and policies.
If this contract is funded by a grant, additional state or federal requirements found in the Notice of Grant Award may be imposed on Respondent;
26. Under §§2155.006 and 2261.053, Government Code, is not ineligible to receive a contract under this RFP and acknowledges that any contract may be terminated and payment withheld if this certification is inaccurate. Sections 2155.006 and 2261.053 relate to violations of federal law in connection with a contract awarded by the federal government for relief, recovery or reconstruction efforts as a result of Hurricanes Rita or Katrina or certain other disasters;
27. Affirms that the statements in these assurances and certifications are true, accurate, and complete (to the best of Respondent’s and its authorized representative’s knowledge and belief), and agrees to comply with the DSHS terms and conditions if an award is issued as a result of this proposal. Willful provision of false information is a criminal offense. Any person making any false, fictitious, or fraudulent statement may, in addition to other remedies available, be subject to civil penalties.
APPENDIX B: GENERAL PROVISIONS
The FY2015 DSHS Core Vendor General Provisions are located at .
APPENDIX C: STANDARDIZED RATES OR APPROVED COSTS
The HCBS-AMH Program is a fee for service program. Rates are available through SYSTEM AGENCY’s website at .
APPENDIX D: LMHA SERVICE REGIONS BY COUNTY
|Region 1: |Anderson, Cherokee |
|Region 2: |Henderson, Smith, Van Zandt, Rains, Wood |
|Region 3: |Travis |
|Region 4: |Jones, Taylor, Shackel-Ford, Callahan, Stephens |
|Region 5: |Burnet, Williamson, Lee, Bastrop, Fayette, Caldwell, Guadalupe, Gonzales |
|Region 6: |Webb, Zapata, Jim Hogg, Starr |
|Region 7: |Robertson, Leon, Madison, Brazos, Grimes, Burleson, Washington |
|Region 8: |Houston, Nacogdoches, Shelby, San Augustine, Angelina, Sabine, Trinity, Polk, San Jacinto, Tyler, Jasper, Newton |
|Region 9: |Maverick, Zavala, Dimmit, Frio, La Salle, Atascosa, McMullen, Wilson, Karnes |
|Region 10: |Bexar |
|Region 11: |Coleman, Brown, Eastland, Comanche, Mills, McCulloch, San Saba |
|Region 12: |Hamilton, Coryell, Lampasas, Bell, Milam |
|Region 13: |Parmer, Castro, Swisher, Briscoe, Bailey, Lamb, Hale, Floyd, Motley |
|Region 14: |Bee, Live Oak, San Patricio, Duval, Jim Wells, Kleberg, Brooks, Kenedy, Aransas |
|Region 15: |Sterling, Coke, Reagan, Irion, Tome Green, Concho, Crockett |
|Region 16: |Dallas, Ellis, Navarro, Kaufman, Rockwall, Hunt |
|Region 17: |Denton |
|Region 18: |El Paso |
|Region 19: |Lavaca, Dewitt, Jackson, Victoria, Goliad, Calhoun, Refugio |
|Region 20: |Galveston, Brazoria |
|Region 21: |Harris |
|Region 22: |Bosque, Hill, McLennan, Limestone, Freestone, Falls |
|Region 23: |Childress, Cottle, Dickens, King, Stonewall, Hardeman, Foard, Knox, Haskell, Wilbarger, Baylor, Throck-Morton, Wichita,|
| |Archer, Young, Clay, Jack, Montague, Wise |
|Region 24: |Val Verde, Schleicher, Sutton, Edwards, Kinney, Menard, Kimble, Real, Uvalde, Mason, Gillespie Kerr, Bandera, Medina, |
| |Llano, Blanco, Kendall, Hays, Comal |
|Region 25: |Hopkins, Lamar, Delta, Franklin, Titus, Camp, Morris |
|Region 26: |Collin |
|Region 27: |Cochran, Hockley, Lubbock, Lynn, Crosby |
|Region 28: |Nueces |
|Region 29: |Palo Pinto, Parker, Erath, Hood, Johnson, Somervell |
|Region 30: |Hudspeth, Culberson, Jeff Davis, Pecos, Presidio, Brewster, Ector, Midland |
|Region 31: |Red River, Bowie, Cass, Marion, Upshur, Gregg, Harrison, Rusk, Panola |
|Region 32: |Hardin, Orange, Jefferson, Chambers |
|Region 33: |Tarrant |
|Region 34: |Austin, Waller, Colorado, Fort Bend, Wharton, Matagorda |
|Region 35: |Dallam, Sherman, Hansford, Ochiltree, Lipscomb, Hartley, Moore, Hutchinson, Roberts, Hemphill, Oldham, Potter, Carson, |
| |Gray, Wheeler, Deaf Smith, Randall, Armstrong, Donley, Collingsworth, Hall |
|Region 36: |Cooke, Grayson, Fannin |
|Region 37: |Walker, Montgomery, Liberty |
|Region 38: |Hidalgo, Willacy, Cameron |
|Region 39: |Runnels, Terrell, Upton, Crane, Ward, Loving, Winkler, Glasscock, Andrews, Martin, Howard, Mitchell, Nolan, Gaines, |
| |Dawson, Borden, Scurry, Fischer, Yoakum, Terry, Garza, Kent, Reeves |
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