Apps.hhs.texas.gov
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Open Enrollment
For
Opioid Treatment Services for Pregnant and Post-Partum Women
Department of State Health Services
Procurement Number: HHS0000027
Enrollment Period Opens: 02/22/2016
Enrollment Period Closes: 08/31/2021
CPA Class/Item Code:
952-05
Addendum #2 (October 12, 2017)
Addendum #1 (March 28, 2016)
TABLE OF CONTENTS
I. INTRODUCTION AND DEFINITIONS 4
A. Introduction 4
B. Definitions 4
II. LIMITATIONS 13
III. FUNDING AND TERM 13
A. Use of Funds 13
B. Funding Obligation 13
C. Term of Contract 14
IV. ELIGIBLE RESPONDENTS 14
A. Eligibility Requirements and Affirmations 14
V. PROGRAM INFORMATION 16
A. Project Overview 16
B. Scope of Work 18
C. Legal Authority 21
D. Program Requirements 21
E. Method of Payment 22
VI. PROCUREMENT AND ADMINISTRATIVE REQUIREMENTS 23
A. OE Point of Contact 23
B. Submission 23
C. Evaluation Process 24
D. Rejection of Enrollment Applications 24
E. Right to Amend OE or Withdraw OE 25
F. Authority to Bind DSHS 25
G. Financial and Administrative Requirements 25
H. Contract Information 25
I. Contracting with Subcontractors 25
VII. APPLICATION INSTRUCTIONS AND CRITERIA FOR ACCEPTANCE 26
VIII. BLANK FORMS AND INSTRUCTIONS 27
FORM A: FACE PAGE 28
FORM B: Open Enrollment Application Checklist 30
FORM C: CONTACT PERSON INFORMATION FORM 31
FORM D: RESPONDENT READINESS 32
IX. APPENDICES 33
APPENDIX A: DSHS ASSURANCES AND CERTIFICATIONS 33
APPENDIX B: UNIFORM CONTRACT TERMS AND CONDITIONS 39
APPENDIX C: FY2016 NEONATAL ABSTINENCE SYNDROME – OPIOID TREATMENT SERVICE RATES 40
APPENDIX D: LOCAL MENTAL HEALTH AUTHORITIES (LMHAs) 41
APPENDIX E: HEALTH AND HUMAN SERVICES REGIONS 46
APPENDIX F: GENERAL AFFIRMATIONS 50
APPENDIX G: NON-EXCLUSIVE LIST OF APPLICABLE LAWS 51
I. INTRODUCTION AND DEFINITIONS
A. Introduction
The Department of State Health Services (DSHS or Department) Mental Health and Substance Abuse Division announces this notice of Open Enrollment (OE) requesting applications to enter into a contract with DSHS. The contract will fund Contractors to provide opioid treatment services (OTS) to pregnant and postpartum opioid-dependent women by providing access to substance use disorder treatment services and to expand and integrate communicable disease testing, immunizations, and chronic disease prevention within the context of OTS. Contractors will bill DSHS for all medication-assisted treatment (MAT) that includes counseling and behavioral therapy to treat adult pregnant and/or postpartum opiate/opioid-dependent women with moderate or severe opiate use disorder.
The contract will fund for OTS to adult pregnant and/or postpartum opiate/opioid-dependent women with moderate or severe opioid use disorder referred for medication-assisted treatment (MAT) including counseling and behavioral therapy.
Eligible respondents will be enrolled in accordance with eligibility requirements.
This OE contains standardized requirements that all respondents must meet to be considered for entering into a contract with DSHS under this OE. Failure to comply with these requirements will result in disqualification of the respondent without further consideration. Each respondent is solely responsible for the preparation and submission of an enrollment application in accordance with instructions contained in the OE.
READ ALL MATERIALS BEFORE RESPONDING TO THIS OPEN ENROLLMENT.
B. Definitions
Standard Definitions
Adult - A person 18 years of age or older, or a person under the age of 18 whose disabilities of minority have been removed by marriage or judicial decree. See also Young Adult.
Appendix – Additional information and/or forms that are located at the end of this document, which are part of this solicitation document.
Applicant - A person who has submitted an application for an initial license to provide chemical dependency counseling or treatment, renewal of a license, or certification or approval for provision of an offender education program.
Assessment - An ongoing process through which the counselor collaborates with the client and others to gather and interpret information necessary for developing and revising a treatment plan and evaluating client progress toward achievement of goals identified in the treatment plan, resulting in comprehensive identification of the client's strengths, weaknesses, and problems/needs.
Authorized Representative - A person designated in writing by a party to represent the party.
Business Day - Any day other than a Saturday, Sunday, or a day in which Texas State offices are authorized or obligated by law or executive order to be closed. See Days.
Capacity – stated number of clients that can be concurrently served, at any given time, as determined by the licensure authority.
Case Management - Services that assist and support clients in developing skills to gain access to and obtain services from needed medical, social, educational and other service providers essential to meeting basic human needs. This function consists of assessment of needs, appropriate referrals, follow-up on referrals, and a plan of action with clear goals.
Child - For purposes of reporting abuse and neglect, a child is a person under the age of 18 whose disabilities of minority have not been removed by marriage or judicial decree. For all other purposes in this OE, child means a person under the age of 13. (See “Adult” and “Adolescent”).
Client - An individual who receives or has received services, including admission authorization or assessment or referral, from a chemical dependency treatment provider, counselor, counselor intern, or applicant for licensure as a counselor, or from an organization where the counselor, intern or applicant is working on a paid or voluntary basis.
Clinical Management for Behavioral Health Services (CMBHS) - a web-based clinical record keeping system for state-contracted community mental health and substance abuse service providers.
Contract – A written agreement referring to promises or agreements for which the law establishes enforceable duties and remedies between a minimum of two parties. A DSHS contract is assembled using a core contract (base), one of more contracts, and other required exhibits (general provisions, etc.).
Contract Term – The period of time during which the contract will be effective from begin date to end, or renewal date.
Contractor – An individual, organization, or entity that contracts with DSHS to provide services and/or goods. This includes (but is not limited to) vendors, sub-recipients, and grantees.
Counseling - A collaborative process that facilitates the client's progress toward mutually determined treatment goals and objectives. Counseling includes methods that are sensitive to client characteristics and to the influence of family and/or significant others, as well as the client's cultural and social context. Competence in counseling is built upon the understanding of, appreciation of, and ability to appropriately use the modalities of care for clients, groups, families, couples, and/or significant others.
Counselor - A Qualified Credentialed Counselor (QCC), graduate or counselor intern working towards licensure that would qualify the person to be a QCC.
Counselor Intern (CI or Intern) - A person seeking a license as a chemical dependency counselor who is registered with the department and pursuing a course of training in chemical dependency counseling at a registered clinical training institution or under the supervision of a certified clinical supervisor.
Days - Calendar days, unless otherwise specified.
Debarment – An exclusion from contracting or subcontracting with state agencies on the basis of cause set forth in Title 34, Texas Administrative Code, §20.105 et seq.
Deliverables – Goods or services contracted for delivery or performance.
Department or DSHS - Department of State Health Services and its branches, divisions, departments, and employees.
Discharge - Formal, documented termination of services.
Discharge Plan - Documentation of the ongoing needs of the client, including the individual goals and activities to sustain recovery; and referrals and recovery maintenance services that have been recommended as the client enters into another level of care.
Due Date – Established deadline for submission of a document or deliverable.
Effective Date – The date the contract term begins.
Entity - A person, business, organization, or LLC that submits a response to a solicitation. For purposes of this document, “entity” is intended to include such phrases as “offeror”. “respondent”, “bidder”, “responder”, or other similar terminology employed by DSHS (or HHSC) 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.
Fiscal Year - The Department's state fiscal year, September 1-August 31, unless otherwise specified.
Fully Executed – A contract that is signed by all of the parties to form a legally binding contractual relationship.
Funded Capacity – stated number of clients that can be concurrently served, at any given time, as determined by the award amount.
HHSC – Health and Human Services Commission
Health Insurance Portability and Accountability Act of 1996 (HIPAA) - Pub. L. No. 104-191, 45 C.F.R. pts. 160 and 164. ()
Hepatitis C Virus (HCV) - Infection with hepatitis C virus.
Human Immunodeficiency Virus (HIV) - The virus that causes Acquired Immune Deficiency Syndrome (AIDS). HIV Infection is determined through a specific testing process. -. Being infected with HIV is not necessarily equated with having a diagnosis of AIDS, which can only be diagnosed by a physician using criteria established by the National Centers for Disease Control and Prevention (CDC).
HIV Antibody Counseling and Testing - A structured HIV testing and risk-reduction session performed by persons who have successfully completed the State of Texas DSHS Protocol-Based Counseling (PBC) training. The protocol is used as a tool to guide the discussion with the client about his/her risk(s) as it relates to HIV, Sexually Transmitted Disease (STD), Hepatitis C Virus (HCV), his/her most recent risk, and the development of - incremental steps to reduce the client’s risk for acquiring or transmitting HIV/STD/HCV.
Individual Counseling - A one-on-one process that facilitates the client’s progress towards mutually determined treatment goals and objectives. Counseling includes methods that are sensitive to individual client characteristics and to the influence of other people, as well as a client’s cultural and social context.
Interim Services - Federally-required activities that include counseling and education about HIV and TB, including the risks of needle-sharing, the risks of transmission to sexual partners and infants, and steps that can be taken to prevent transmission. Referrals for HIV or tuberculosis treatment must be provided if necessary. For pregnant females, interim services include counseling about the effects of alcohol and drug use on the fetus and referrals for prenatal care.
License - A permit, certificate, approval, registration, or similar form of permission issued or granted by a governmental agency as authorized by law.
Licensed Chemical Dependency Counselor (LCDC) - A counselor licensed by the Department pursuant to Occupations Code ch. 504.
Medicaid Management Information System (MMIS) - Automated management and control system for Medicaid payments.
National Provider Identifier (NPI) - A unique identifier assigned by the National Plan and Provider Enumeration System (NPPES). More information about NPI numbers can be found on the Centers for Medicare and Medicaid Services (CMS) website at: .
Office of Management and Budget (OMB) - The federal office that establishes general allowability criteria for all costs charged to a DSHS-funded contract, published in the Office of Management and Budget Circulars (). Different types of organizations are governed by different cost principles promulgated by the Federal OMB.
Opioid Treatment Provider (OTP) - An organization that includes a physician who administers or dispenses a narcotic drug to a narcotic addict for treatment that is certified by SAMHSA and is registered with the U.S. Drug Enforcement Administration (DEA) to use a narcotic drug for the treatment of narcotic addiction.
Opioid Treatment Services (OTS) - Treatment services for opioid-dependent individuals to alleviate adverse physiological effects of withdrawal from the use of opiates and to detoxify the client to a drug-free state over a period of time which is established on an individual basis to meet the needs of the client.
OSAR - DSHS-funded contractor providing outreach, screening, assessment, and referral services.
Outreach - Activities directed toward finding persons who might not use services due to lack of awareness or active avoidance.
Postpartum -18 months or less following birth of youngest child.
Prevention - A proactive process that uses multiple strategies to preclude the illegal use of alcohol, tobacco and other drugs and to foster safe, healthy, drug-free environments.
Procurement and Contracting Services (PCS) – The division within the Health and Human Services Commission (HHSC) 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 DSHS, as authorized by state or federal law, for a specific purpose (“program”) or DSHS staff located in a program, region, or hospital that identify and request procurement needs (“Program”). The Program partners with PCS on procurements.
Project – All work to be performed as a result of a contract or solicitation
Project Period – The anticipated duration of the entire Project stated in total number of budget periods.
Provider - A person that performs or offers to perform substance abuse services. The term includes but is not limited to, a qualified credentialed counselor, applicant for counselor licensure, and counselor intern.
Provider of Last Resort – An entity that is the only willing and qualified entity in a geographic area the individual chooses to provide the service.
Referral - The process of identifying appropriate services and providing the information and assistance needed to obtain access to them.
Region - One of eleven geographic subdivisions of the state [Health and Human Services (HHSC) regions] . A listing of the regions and their associated counties along with the regional Local Mental Health Authorities (LMHAs) is listed in Appendix E.
Relapse - A break in the recovery process that, if left unaddressed, eventually may lead to a return to substance use.
Residential Site - A physical location owned, leased, or operated by a provider where clients reside in a supervised treatment environment.
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”, “applicant”, “bidder”, “responder”, or other similar terminology employed by DSHS (or HHSC) to describe the person or entity that responds to a solicitation.
Rules - A state agency’s statement of general applicability that implements or prescribes law or policy by defining general standards of conduct, rights, or obligations of persons; or describes the procedure or practice requirements that prescribe the manner in which public business before an agency may be initiated, scheduled, or conducted; or interprets or clarifies law or agency policy. The term includes the amendment or repeal of a prior rule, but does not include statements concerning only the internal management or organization of the agency and that does not affect private rights or procedures. This definition includes regulations. Any reference to the rules herein means Department rules published in the Texas Administrative Code and currently in effect unless otherwise specified.
Scope of Work (SOW) – A description of the services and/or goods, if any, for each service type, to be obtained as a result of this solicitation.
Screening - The process through which a qualified staff member, client or participant, and available family determine the most appropriate initial course of action given the client's needs and characteristics and the available resources within the community. In a treatment program, screening includes determining whether a client is appropriate and eligible for admission to OTS.
Service Area - The geographical area that a Respondent will serve.
Services - Substance abuse services unless otherwise identified. See also Substance Abuse Services.
Sexually Transmitted Disease (STD) - Infectious diseases transmitted mainly through sexual activity, although some STD’s can be transmitted by sharing injection equipment.
Signature - Authentication of a record that meets the criteria established in 25 Texas Administrative Code §448.507 (relating to General Documentation Requirements).
Social Services - Services designed to improve the client’s standard of living such as education, food subsidies, healthcare, housing, and rehabilitative services.
Solicitation – The process of notifying prospective contractors of an opportunity to provide goods or services to the state (e.g., this OE).
Special Provisions – Modifications or additions to the UTCs for a funded program activity, which are usually customized for the Program’s requirements and contain provisions specific to the Contract.
Staff - Individuals working for a person in exchange for money or other compensation.
Standards of Care - Written rules in the Texas Administrative Code for facilities and staff to protect the health, safety, and welfare of those receiving substance abuse services and to ensure that substance abuse treatment services are delivered in a competent manner.
Statement of Work – The description of services and/or goods to be delivered by the DSHS contractor specifying the type, level and quality of service, that directly relate to program objectives.
Substance Abuse - A maladaptive pattern of substance use leading to clinically significant impairment or distress, as defined by the most recently published version of the DSM.
Substance Abuse and Mental Health Services Administration (SAMHSA) - Is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities. ()
Substance Use Disorder Treatment Services – (Chemical Dependency Treatment) A planned, structured, and organized chemical dependency program designed to initiate and promote a person's chemical-free status or to maintain the person free of illegal drugs. It includes, but is not limited to, the application of planned procedures to identify and change patterns of behavior related to or resulting from substance-related disorders that are maladaptive, destructive, or injurious to health, or to restore appropriate levels of physical, psychological, or social functioning.
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 PE, 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 (SSA) or by the IRS.
Texas Administrative Code (TAC) - A compilation of all state agency rules in Texas. Rules of the Department are found in Title 25. ().
TMHP – Texas Medicaid and Healthcare Partnership
Texas Provider Identifier (TPI) - Number issued by Texas Medicaid (HHSC) to identify individual healthcare provider locations.
Treatment Planning - A collaborative process through which the provider and client develop desired treatment outcomes and identify the strategies for achieving them. At a minimum, the treatment plan addresses the identified substance use disorder(s), as well as issues related to treatment progress, including relationships with family and/or significant others, employment, education, spirituality, health concerns, and legal needs.
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.
U.S. Drug Enforcement Administration (DEA) -
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 DSHS-funded program. Under a vendor contract, the vendor will have few if any administrate 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 DSHS-funded clients in the same manner the vendor would deliver those services to its non-DSHS-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. or VIN) – Fourteen-digit number needed for any respondent 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 VIN 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 DSHS and incorporated in the contract.
II. LIMITATIONS
Issuance of this OE in no way constitutes a commitment by DSHS 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 contract will be subject to the availability of state and federal funds. Contracts awarded under this OE and any anticipated contract renewals are contingent upon the continued availability of funding. DSHS reserves the right to alter, amend or withdraw this OE at any time prior to the execution of a contract. If a contract has been fully executed and this OE is altered, amended, or withdrawn, DSHS and contractor’s obligations and rights will be determined in accordance with the provisions of the contract.
III. FUNDING AND TERM
A. Use of Funds
Contracts will be awarded for the purpose specifically defined in this OE and must not be used for any other purposes. DSHS will review applications in the order in which they are received on a first-come, first-served basis. Funding per Region for OTS will vary, DSHS will cap funding for a Region once coverage for OTS has been met. OTS rates established by DSHS will be the payment methodology for services provided by a contractor (refer to Appendix C).
Selected contractor will be permitted to operate within the funded capacity indicated in the contract for the duration of the contract term. Submitted claims in excess of the selected contractor’s stated funded capacity will be approved for payment based on availability of funds.
DSHS, at its sole discretion, may adjust the funded capacity of a contract based on performance measures, outcome measures, waitlist, and/or other criteria determined by DSHS, and contingent on availability of funds.
DSHS does not guarantee a minimum amount to be paid to a contractor pursuant to a 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, DSHS may restrict, reduce or terminate funding under this Contract. Notice of any restriction or reduction shall include instructions and detailed information on how DSHS shall fund the services and/or goods to be procured with the restricted or reduced funds.
C. Term of Contract
Contracts awarded under this OE will begin on the date of execution through August 31, 2016. DSHS may, at its sole discretion, renew a contract after the initial term. The contracts may be renewed up to four additional one- year period contract terms. Renewal is contingent upon the availability of funds and the satisfactory performance of the contractor during the prior contract period.
IV. ELIGIBLE RESPONDENTS
A. Eligibility Requirements and Affirmations
Eligible respondents include governmental, for-profit, and non-profit entities to submit applications for each clinic site for the administration of medication-assisted treatment which includes dispensing of medications approved to treat opioid use disorders along with behavioral health counseling and must comply with the criteria listed below.
If Respondent has multiple clinic sites, Respondent must submit a separate application for each clinic site.
The respondent must submit all documents required in this OE. A respondent is not considered eligible unless the respondent meets the following conditions by the date of application and continues to meet these conditions throughout the duration of the contract. DSHS will review and analyze the documentation submitted to determine respondent’s eligibility.
1. 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.
2. Contractors must provide proof of state licensure as a Narcotic Treatment Clinic (NTC)
.
3. Respondents must provide documented proof of Substance Abuse and Mental Health Services Administration (SAMHSA) certification and DEA registration as a qualified opioid treatment program (OTP) with their application. Under federal opioid treatment standards found in Title 42 of the Code of Federal Regulations Part 8 (42 CFR § 8), OTPs are required to have current valid accreditation status, SAMHSA certification, and Drug Enforcement Administration (DEA) registration prior to administering or dispensing of opioid drugs for the treatment of opioid addiction. Refer to Federal Guidelines for Opioid Treatment Programs (Guidelines)
4. Respondent must demonstrate their capacity to bill insurance and Medicaid for those clients with insurance coverage. Funds under this OE can only be used as payment of last resort which means that other applicable reimbursement resources such as Medicaid or other 3rd party payers must be billed first.
5. Respondent must have a principal place of business in the State of Texas. 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 prior to the date that the contract is awarded.
6. Respondent must be in good standing with the U.S. Internal Revenue Service.
7. Respondent affirms they are not currently debarred, suspended, or otherwise excluded or ineligible for participation in Federal or State assistance programs.
8. 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.
9. A respondent is not considered eligible to contract with DSHS 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
b. Texas Comptroller of Public Accounts (CPA) Debarment List located at
10. Respondent must maintain the organization’s certification and licensure compliance with applicable statutes, guidelines, and regulations related to opioid treatment services adopted by DSHS, SAMHSA, Center for Substance Abuse Treatment (CSAT), and the Drug Enforcement Administration (DEA).
11. Respondent must maintain the organization’s compliance with rules adopted by DSHS related to providing OTS to adult pregnant and/or postpartum women as stated in Title 25 of the Texas Administrative Code (TAC) and Code of Federal Regulations (CFR).
a. Chapter 229, Subchapter J – Minimum Standards for Narcotic Treatment Programs;
b. Chapter 441 - General Provisions;
c. Chapter 442 - Investigations and Hearings; and
d. 42 CFR, part 8, Opioid Drugs in Maintenance and Detoxification Treatment of Opiate Addiction; Final Rule.
12. Respondent must ensure that staff providing direct OTP services maintain certification and licensure compliance with applicable statutes, guidelines, and regulations adopted by DSHS, SAMHSA, CSAT, and the DEA throughout the term of this Contract.
13. Respondent must ensure that staff providing direct OTP services maintain their professional license compliance with rules adopted by DSHS as stated in Title 25 of the Texas Administrative Code (TAC), Chapter 140 Health Professions Regulation, Subchapter I. Licensed Chemical Dependency Counselors (LCDCs) throughout the term of this Contract.
14. Respondent must have proof of insurance.
a. HHSC’s Uniform Contract Terms and Conditions (UTCs), Version 2.12.
V. PROGRAM INFORMATION
8 Project Overview
The DSHS-funded OTS provider will provide substance use disorder treatment services to adult pregnant and/or postpartum opiate/opioid-dependent women with moderate or severe opioid use disorder referred for medication-assisted treatment and counseling/behavioral therapy.
Adult pregnant and/or postpartum opiate/opioid-dependent women may be referred to as “clients” in this OE.
DSHS-funded OTS providers must develop formal documented agreements with the local DSHS-funded Pregnant Postpartum Intervention (PPI) provider, and community, health, or social services agencies for referrals and to exchange appropriate information in accordance with HIPAA regulations and 42 CFR § 2. OTS providers will accept clients referred to services through the local in-house PPI provider.
Through a comprehensive resource network of community, health, or social services agencies, clients will be referred to a local DSHS-funded PPI provider located on OTS provider’s site to conduct screening and eligibility determinations and document referral to OTS in the client record. Clients seeking OTS must be given priority for interim maintenance therapy. Reasons for denying admission to a pregnant and/or postpartum opiate/opioid-dependent client must be documented in the client record and DSHS program services staff must be contacted immediately.
The DSHS-funded OTS provider, through formal documented agreement with the local in-house PPI provider, will coordinate services to ensure that every client referred to OTS receives care coordination and case management through the in-house PPI provider. Services include assistance in removing any barriers to clients needing access to treatment and ensuring provision of parenting education, prenatal care, reproductive health education, and education on Neonatal Abstinence Syndrome (NAS), Fetal Alcohol Spectrum Disorders (FASD) and tobacco use.
The DSHS-funded OTS provider must have formal documented agreements and informed consent procedures in place that ensure reciprocity in the exchange of pertinent clinical information regarding compliance with the recommended course of medication-assisted treatment including counseling/behavioral therapy. If a client refuses the offered services, the treating physician or authorized healthcare professional, as appropriate, may use informed consent procedures to have the client formally acknowledge, in writing, client’s refusal of these services. Policies forbidding children in the OTS provider’s facility are not appropriate. Every attempt should be made to provide a safe and supportive environment for parents and their children.
For clients receiving methadone or buprenorphine, the DSHS-funded OTS provider must have procedures in place to ensure monitoring and dosing protocols.
The DSHS-funded OTS provider must establish and implement procedures, including informed consent to ensure appropriate medication-assisted treatment and counseling/behavioral therapy services. Informed consent refers to the client’s agreement to receive treatment as well as to release information to and obtain information from the in-house DSHS-funded PPI provider and local community, health, or social services providers through established formal agreements. Appropriate counseling and informed decision making between DSHS-funded OTS provider and the client must take place and be documented in the client’s record.
The DSHS-funded OTS provider must have procedures in place for documenting OTS-related activities and testing as stated in the Scope of Work (SOW) below.
Clients should be encouraged to consider ongoing maintenance treatment after delivery. Medically-supervised withdrawal after pregnancy should occur only when clinically indicated or requested by the client. If a client is discharged, the DSHS-funded OTS provider must identify a specific physician or authorized healthcare professional, as appropriate, to whom the client is being discharged. The name, address, and telephone number of the provider caring for the client after discharge are to be recorded in the patient’s record. Clients will be asked to complete a satisfaction survey upon discharge.
Resources:
Federal Guidelines for Opioid Treatment Programs
42 Code of Federal Regulations Part 8 - Certification of Opioid Treatment Programs
Texas Administrative Code (TAC) Chapter 229, Subchapter J: Minimum Standards for Narcotic Treatment Programs
DSHS Regulatory Services, License Application Form for Narcotic Treatment Clinics
Medication for the Treatment of Alcohol Use Disorder: A Brief Guide
Medication-Assisted Treatment for Opioid Addiction: Facts for Families and Friends, 2009
Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Chapter 13. Medication-Assisted Treatment for Opioid Addiction during Pregnancy
Medication-Assisted Treatment (MAT) Program. Informational web link to SAMHSA’s MAT Program
SAMHSA’s Opioid Overdose Prevention Tool Kit .
B. Scope of Work
Contractor(s) must expend funds under the Contract to administer and dispense medications approved for the treatment of opioid addiction along with providing counseling and behavioral therapy. Contractor must provide substance use disorder treatment services to adult pregnant and/or postpartum opiate/opioid-dependent women with moderate or severe opiate use disorder. OTS alleviate the adverse physiological effects of withdrawal from the use of opiates as required to meet the individualized needs of the client. To expand and integrate communicable disease testing, immunizations, and chronic disease prevention within the context of OTS in order to provide clients with an opportunity to improve their health and the quality of their overall lives while also obtaining help for their substance use disorder.
Objectives:
To provide OTS to adult pregnant and/or postpartum opiate/opioid-dependent women to reduce risk of fetal morbidity and fetal mortality, and the risk of parental substance use.
Administrative and Organizational Requirements:
1. Contractor must house a DSHS-funded PPI services contractor to be available onsite daily including but not limited to conduct screenings; eligibility determinations; care coordination; case management services including assistance in removing barriers to clients needing access to treatment; provision of parenting education, reproductive health education, and education on Neonatal Abstinence Syndrome.
a. Through onsite DSHS-funded PPI contractor services, Contractor(s) must ensure that children of the client have access to services to address their needs and support healthy development.
Service Delivery:
Contractor must perform the following:
1. Medication and Counseling Treatment
a. Contractor must provide medication-assisted treatment (MAT) that includes counseling and behavioral therapy to treat adult pregnant and/or postpartum opiate/opioid-dependent women with moderate or severe opiate use disorder.
b. Services may be provided to clients who are pregnant or post-partum. Post-partum is defined as 18 months or less after delivery.
c. Contractor must provide MAT that includes individual and group counseling services in conjunction with medications, namely methadone and buprenorphine approved in the treatment of opioid use disorders.
d. Contractor shall provide overdose prevention education to clients on Contractor’s waiting list. Contractor shall also provide overdose prevention education to all clients prior to discharge, including those that received it prior to admission:
1. General overdose prevention education shall be provided to all clients as a part of treatment education requirements to include education on naloxone (including possible local access if available).
2. Specific overdose prevention activities shall be conducted with clients with opioid use disorders and those clients that use drugs intravenously to include:
a) Education on naloxone (including possible local access if available);
b) Education about and referral to DSHS-funded HIV Outreach services for clients with IV drug use history; and
c) Referral to local community resources that work to reduce harm associated with high risk behaviors associated with drug use.
d) For detailed guidance please refer to SAMHSA’s Opioid Overdose Prevention Tool Kit found at .
e. Contractor may deliver methadone/buprenorphine to clients in a residential treatment facility, a jail or correction facility, or medically necessary approved by physician. Contractor must submit notification form to DSHS within 72 hours to the designated SA CMU Mailbox email of transport of medication and counseling services offsite to individuals that are restricted to the home for medical reasons or are in a restricted environment including jails and residential treatment centers.
2. Documentation and Testing
a. Contractor must document opioid treatment-related activities and services, and testing in the DSHS CMBHS system. This information collected in CMBHS will assist DSHS in determining the number of clients served and the opioid treatment-related services and activities provided by the Contractor(s).
b. Contractor must provide and document provision of medication and counseling in CMBHS.
c. Contractor must provide and document in an administrative note in CMBHS the transport of medication and counseling services offsite for individuals that are restricted to the home for medical reasons or are in a restricted environment including jails and residential treatment centers.
d. Contractor must attach the informed consent form to an administrative note and record clinical documentation into the client’s CMBHS record; e.g. diagnostic tests such as the Clinical Institute Withdrawal Assessment or Beck Depression Inventory, physician orders, etc.
e. Contractor must include the routine, opt-out screening, testing, and immunization services on its standard consent to treat form and upload in CMBHS.
f. Contractor must provide or arrange for interim services including screening for tuberculosis, hepatitis B and C, sexually transmitted diseases (STD), and Human Immunodeficiency Virus (HIV) and document in CMBHS.
g. Contractor must provide and document in CMBHS health screenings, testing, immunizations, and prevention education. Contractor(s) must use the funds and associated billing codes provided through this contract to directly provide the following services, while only subcontracting laboratory services:
1. Routine, opt-out screening and testing for the following: tuberculosis, hepatitis B and C, syphilis, gonorrhea, chlamydia, Human Immunodeficiency Virus (HIV), diabetes (using A1c testing) and obesity for all DSHS-funded clients.
2. Routine, opt-out immunizations for hepatitis B and C and Tetanus.
h. Contractor(s) must document the needs of the client in CMBHS, including medical care and behavioral healthcare needs. The treatment plan must include courtesy dosing/temporary transfer, discharge criteria, and discharge plan.
3. Annual Survey
a. Contractor must collect the OTS Annual Survey.
b. Contractor must use the DSHS-approved client satisfaction OTS Annual survey template for collecting information from clients who have received OTS.
c. Contractor must have a process for collecting client survey data.
d. Contractor must submit results of client surveys in an annual report to DSHS. Annual report due date to be determined by DSHS.
4. Conference Calls
a. Contractor’s program directors must participate in monthly conference calls as scheduled by DSHS to address programmatic, documentation, or testing issues.
Reporting, Billing, and CMBHS Requirements:
1. Contractor must use the DSHS CMBHS.
2. Contractor must submit monthly claims through CMBHS and must be reimbursed for services provided under this Contract utilizing the established unit rates.
3. Contractor must designate a Security Administrator and a back-up Security Administrator. The Security Administrator is required to implement and maintain a system for management of user accounts/user roles to ensure that all the CMBHS user accounts are current.
4. Contractor must establish and maintain a security policy that ensures adequate system security and protection of confidential information.
5. Contractor must notify the CMBHS Help-desk within ten (10) business days of any change to the designated Security Administrator or the back-up Security Administrator.
a. Contractor must ensure that access to CMBHS is restricted to only authorized users. Contractor(s) must, within 24 hours, remove access to users who are no longer authorized to have access to secure data.
b. In addition to CMBHS Helpdesk notification, Contractor must submit a signed CMBHS Security Attestation Form and a list of Contractor’s employees, contracted laborers and subcontractors authorized to have access to secure data.
c. Contractor must submit the CMBHS Security Attestation Form electronically biannually as designated by DSHS to the designated Substance Abuse mailbox.
6. Contractor must submit all documents identified in the Contract by the required due date.
|Report Name |Due |
|CMBHS Security Attestation Form and list of authorized users |Due 15th day after contract execution and as designated |
| |by DSHS |
|CMBHS documentation and testing |Ongoing |
|Client Satisfaction Survey |Ongoing |
|OTS Annual Survey Report |9/30/16 |
|Closeout documents |Due 45 days after Contract end date |
7. Contractor’s duty to submit documents survives the termination or expiration of this Contract.
C. Legal Authority
DSHS is authorized to enter into contracts under this OE by Texas Health and Safety Code Chapter 12. The HCBS-AMH Program is administered under Social Security Act §1915(i). HHSC, as the Texas Medicaid Agency, delegated administration of the HCBS-AMH Program to DSHS as authorized by Texas Government Code §531.0055.
D. 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 Health and Human Services Commission (HHSC) Civil Rights Office website at: .
Upon request, a contractor must provide the HHSC Civil Rights Office with copies of all the contractor’s civil rights policies and procedures. Contractors must notify HHSC’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 on the DSHS website at:
.
DSHS reserves the right to modify the Statement of Work of the contract and to incorporate Special Provisions into contracts awarded under this OE.
DSHS reserves the right to perform a Quality Management review at the department’s sole discretion.
E. Method of Payment
When a contract is executed, Contractor shall submit claims to DSHS through CMBHS. DSHS will pay Contractor for opioid treatment services, counseling and behavioral therapy based on established rates. (Appendix C)
Payment shall be provided by DSHS to Contractor in accordance with the provisions stated in the contract. Respondent shall request payment using the claims process described in the contract to request payment of the required services and deliverables.
VI. PROCUREMENT AND ADMINISTRATIVE REQUIREMENTS
A. OE Point of Contact
For purposes of submitting questions concerning this OE, the only contact is Norma Rios 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: Norma.Rios@hhsc.state.tx.us
Other employees and representatives of DSHS are not permitted to answer questions or otherwise discuss the contents of the OE with any respondent or potential respondent 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 (preferred), mail, hand-delivery, or fax to the addresses or numbers above.
DSHS will post answers to questions to the HHS Opportunities Page as appropriate. DSHS reserves the right to amend answers prior to the open enrollment closing date.
B. Submission
The completed enrollment application, which includes all forms, must be submitted to the physical address specified below. Emailed applications will be acceptable.
Substance Abuse Contract Management Unit (MC 2058)
Health and Human Services Commission
ATTN: Norma Rios
Procurement #: HHS0000027
909 West 45th, Bldg. 552
Austin, Texas 78751
Substance Abuse Contracts Management Mailbox:
SubstanceAbuse.Contracts@dshs.
C. Evaluation Process
Enrollment applications will be evaluated according to the criteria below. All enrollment applications remain with DSHS 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, in Section IV. Eligible Respondent.
2. Other screening criteria as follows:
a. FORM A: Face Page
b. FORM B: Open Enrollment Application Checklist
c. FORM C: Contact Person Information Form
d. FORM D: Respondent Readiness documents
3. After the screening, OE Point of Contact will delegate direct communications to DSHS program for other evaluation purposes.
4. The respondent may be subject to an Onsite Review which may include the following information, when applicable.
a. Information submitted as a part of the OE application;
b. Additional information as requested at the discretion of DSHS.
In conducting the evaluation process, DSHS at its sole discretion may give Respondent 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.
Provisions of the contract will be determined at the sole discretion of DSHS staff.
D. Rejection of Enrollment Applications
1. DSHS 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 DSHS’s review through contact with any Commissioner or staff member of DSHS 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 DSHS 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, the Respondent must correct the item(s) identified in the rejection letter and submit a complete application according to Section VI. A. OE Point of Contact.
E. Right to Amend OE or Withdraw OE
DSHS 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 DSHS and the State of Texas. The decision of DSHS is administratively final. Amendment or notice of withdrawal of the OE will be posted to the HHS Opportunities Page.
F. Authority to Bind DSHS
For the purposes of this OE, the Commissioner of DSHS, 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 DSHS 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
Uniform Terms and Conditions
1. All contractors under this OE must comply with HHSC’s Uniform Contract Terms and Conditions (UTCs), Version 2.12 found in Package 2.
2. Respondent is not required to return the UTCs or DSHS Assurances and Certifications with their enrollment application. By signing the Form A: Face Page, respondent is agreeing to abide by the referenced UTCs and DSHS Assurances and Certifications.
H. 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 application submitted to DSHS for consideration. DSHS will accept or reject each proposed exception. DSHS reserves the right to adjust the funding allocation to contractors pursuant to the terms of the contract.
I. Contracting with Subcontractors
Contracting with direct-service licensed Narcotic Treatment Clinic providers for Opioid Treatment Services, the selected respondent may not enter into contracts with subcontractors for performance of the direct-service delivery requirements of the contract.
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
FORM D: Respondent Readiness documents
Respondent shall submit all documents required in this OE. An application must be complete to be considered. DSHS expressly reserves the right to review and analyze the documentation submitted and determine the respondent’s eligibility for open enrollment.
Respondent Signature. Applications must contain original signatures on all forms requiring signatures.
Application Preparation and Assembly. 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. Entities that meet the eligibility requirements and submit the signed and completed forms included in this OE will pass the evaluation.
VIII. BLANK FORMS AND INSTRUCTIONS
Department of State Health Services
FORM A: FACE PAGE
OPEN ENROLLMENT #: HHS0000027
This form requests basic information about the respondent and project, including the signature of the authorized representative. NOTE: Respondent must submit a separate and complete enrollment application and required documents for each clinic site.
|RESPONDENT INFORMATION |
|1) LEGAL NAME: | |
|2) 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) 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 | |
| | | |
|6) REGION and COUNTY(IES) TO BE SERVED BY THE CLINIC SITE: (Refer to | |
|Appendix E) | |
| | |
|7) PROJECT CONTACT PERSON | | |
| Name: | | | | | |
|Phone: | | | | | |
|Fax: | | | | | |
|E-mail: | | | | | |
|The facts affirmed by me in this application are truthful and I warrant that the applicant 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 applicant and I (the person signing below) am authorized to represent the applicant. |
|8) AUTHORIZED REPRESENTATIVE | |9) SIGNATURE OF AUTHORIZED REPRESENTATIVE |
| |Name: | | |
| |Title: | | |
| |Phone: | | |
| |Fax: | | |
| |E-mail: | | |
| | | |10) DATE |
| | | | | |
GENERAL INSTRUCTIONS FOR THE FACE PAGE
This form provides basic information about the applicant and the proposed project with the Department of State Health Services (DSHS), 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 applicant’s response are truthful and that the applicant 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 applicant’s enrollment application.
1) LEGAL NAME - Enter the legal name of the applicant.
2) MAILING ADDRESS INFORMATION - Enter the applicant’s complete street and mailing address, city, county, state, and 9-digit zip code.
3) PAYEE MAILING ADDRESS - Payee – Entity involved in a contractual relationship with applicant to receive payment for services rendered by applicant 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 applicant. 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) 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.
6) REGION AND COUNTY(IES) SERVED BY CLINIC SITE - Enter the region and county(ies) to be served by the clinic site. Refer to Appendix E provided.
7) PROJECT CONTACT PERSON - Enter the name, phone, fax, and e-mail address of the person responsible for the proposed project.
8) AUTHORIZED REPRESENTATIVE - Enter the name, title, phone, fax, and e-mail address of the person authorized to represent the applicant. Check the “Check if change” box if the authorized representative is different from previous submission to DSHS.
9) SIGNATURE OF AUTHORIZED REPRESENTATIVE - The person authorized to represent the applicant must sign in this blank.
10) DATE - Enter the date the authorized representative signed this form.
FORM B: Open Enrollment Application Checklist
Each Enrollment Application Must Contain the Following Items. NOTE: Respondent must submit a separate and complete enrollment application and required documents for each clinic site.
|Document |Check (√), if included |
| | |
|FORM A: DSHS Face Page – Signature Required | |
| | |
|FORM B: Open Enrollment Application Checklist | |
|FORM C: Contact Person Information Form | |
|FORM D: Respondent Readiness (provide items listed below) | |
|Clinic Site/License Information | |
|Proof of DSHS facility licensure as a Narcotic Treatment Clinic | |
|Proof of SAMHSA certification | |
|Proof of accreditation by an independent SAMHSA accrediting body | |
|Proof of DEA registration as a qualified NTC | |
|Copy of respondent’s organization chart | |
|Texas Medicaid and Healthcare Partnership Information – Texas Provider Identifier (TPI) number | |
|Medicaid Information – National Provider Identifier (NPI) number | |
|Proof of Insurance | |
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: RESPONDENT READINESS
This section details the respondent’s readiness as it relates to project described in this OE. NOTE: Respondent must submit a separate and complete enrollment application and required documents for each clinic site.
|Respondent Organization Name | |
|Region | |
|License Number | |
|Clinic’s Physical Address, | |
|City, & Zip Code | |
|County | |
|DSHS Committed Capacity | |
|Attach documentation of current facility licensure as a Narcotic Treatment Clinic (NTC). Date DSHS facility licensure was issued for NTC. NOTE: |
|DSHS facility licensure must be held directly by your organization. |
|Provide proof of SAMHSA certification. Attach documentation of SAMHSA certification. |
|Provide proof of accreditation by an independent SAMHSA accrediting body. |
|Provide proof of DEA registration as a qualified NTC. DEA Number: |
|Attach respondent’s organization chart, detailing oversight structure (governing body) and staff who will manage clinical services (two-page |
|limit). |
|Provide copy of Texas Medicaid and Healthcare Partnership (TMHP) that lists enrollment date, effective date, and Texas Provider Identifier (TPI) |
|number. |
|Provide organization’s Medicaid provider (NPI) number. |
|Attach proof of insurance. |
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, an Respondent is ineligible to receive an award under this OE if the bid includes financial participation with the Respondent by a person who received compensation from DSHS to participate in preparing the specification of OE 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 OE 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 OE;
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 OE 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 open enrollment application. 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: UNIFORM CONTRACT TERMS AND CONDITIONS
HHSC’s Uniform Contract Terms and Conditions (UTCs) can be found in Package 2 of the posting.
APPENDIX C: FY2016 NEONATAL ABSTINENCE SYNDROME – OPIOID TREATMENT SERVICE RATES
|As of 11/20/15 |
|Treatment Service Types |Program |Activity |per hour/day |Days or Units |Estimated |
| |ID |Unit Rate* |test/visit |(LOS) |Average |
| | | | | |Cost/Client |
|NAS Opioid Therapy Services (OTS) 1 | | | | | |
| |Medication Assisted Therapy (MAT) -comprehensive medication|SA/NAS-OTS | $ 20.00 |qtr hr |4 | $ 80.00 |
| |services per 15 minutes (max 4 units per day) | | | | | |
| |Hepatitis B |SA/NAS-OTS | $ 11.84 |test |1 | $ 11.84 |
| |Hepatitis C |SA/NAS-OTS | $ 16.35 |test |1 | $ 16.35 |
| |HIV (initial) |SA/NAS-OTS | $ 27.60 |test |1 | $ 27.60 |
| |HIV (confirmatory) |SA/NAS-OTS | $ 10.18 |test |1 | $ 10.18 |
| |Gonorrhea |SA/NAS-OTS | $ 40.21 |test |1 | $ 40.21 |
| |Chlamydia |SA/NAS-OTS | $ 40.21 |test |1 | $ 40.21 |
| |Diabetes |SA/NAS-OTS | $ 11.12 |test |1 | $ 11.12 |
| |Outpatient Visit - Follow-up (Results/Linkages) |SA/NAS-OTS | $ 33.27 |visit |1 | $ 33.27 |
| |Urine Pregnancy Test |SA/NAS-OTS | $ 7.49 |test |1 | $ 7.49 |
|Notes: | | | | | |
| |* Based on Texas Medicaid rates. Subject to change. |
|1 |NAS OTS services may be provided to clients who are pregnant or post-partum. Post-partum is defined as 18 months or less after delivery.|
|2 |Delivery of methadone/buprenorphine to clients in: a residential treatment facility, a jail or correction facility, or medically |
| |necessary approved by physician. Contractor must submit notification form to DSHS within 72 hours to the designated SA CMU Mailbox email|
| |of transport of medication and counseling services offsite to individuals that are restricted to the home for medical reasons or are in a|
| |restricted environment including jails and residential treatment centers. |
APPENDIX D: LOCAL MENTAL HEALTH AUTHORITIES (LMHAs)
Abilene
Betty Hardwick Center 800-758-3344
Counties Served: Callahan, Jones, Shackelford, Stephens, Taylor[pic]
Amarillo
Texas Panhandle MHMR
806-359-6699 / 800-692-4039
Counties Served: Armstrong, Carson, Collingsworth, Dallam, Deaf Smith, Donley, Gray, Hall, Hansford, Hartley, Hemphill, Hutchinson, Lipscomb, Moore, Ochiltree, Oldham, Potter, Randall, Roberts, Sherman, Wheeler
[pic]
Austin
Austin Travis County MHMR Center
512-472-4357
Counties Served: Travis
[pic]
Beaumont
Spindletop MHMR Services
409-838-1818
Counties Served: Chambers, Hardin, Jefferson, Orange
[pic]
Big Spring
West Texas Centers for MHMR 800-375-4357
Counties Served: Andrews, Borden, Crane, Dawson, Fisher, Gaines, Garza, Glasscock, Howard, Kent, Loving, Martin, Mitchell, Nolan, Reeves, Runnels, Scurry, Terrell, Terry, Upton, Ward, Winkler, Yoakum
[pic]
Brownwood
The Center for Life Resources 866-558-4357
Counties Served: Brown, Coleman, Comanche, Eastland, McCulloch, Mills, San Saba
[pic]
Bryan
MHMR Authority of Brazos Valley
800-282-6467
Counties Served: Brazos, Burleson, Grimes, Leon, Madison, Robertson, Washington
[pic]
Conroe
Tri-County MHMR Services
800-659-6994
Counties Served: Liberty, Montgomery, Walker
[pic]
Corpus Christi
MHMR Center of Nueces County
361-886-6900
Counties Served: Nueces
[pic]
Dallas
Metrocare Services
214-743-1200
Counties Served: Dallas
[pic]
Denton
Denton County MHMR
800-762-0157
Counties Served: Denton
[pic]
Edinburg
Tropical Texas Behavioral Health
800-813-1233
Counties Served: Cameron, Hidalgo, Willacy
[pic]
El Paso
El Paso MHMR
915-779-1800 / 877-562-6467
Counties Served: El Paso
[pic]
Fort Worth
MHMR of Tarrant County 817-335-3022
Counties Served: Tarrant
[pic]
Galveston
The Gulf Coast Center
866-729-3848
Counties Served: Brazoria, Galveston
[pic]
Houston
MHMR Authority of Harris County
866-970-4770
Counties Served: Harris
[pic]
Jacksonville
ACCESS
800-621-1693
Counties Served: Anderson, Cherokee
[pic]
Kerrville
Hill Country Community MHMR Center 877-466-0660
Counties Served: Bandera, Blanco, Comal, Edwards, Gillespie, Hays, Kendall, Kerr, Kimble, Kinney, Llano, Mason, Medina, Menard, Real, Schleicher, Sutton, Uvalde, Val Verde
[pic]
Laredo
Border Region MHMR
800-687-4239 / 800-287-4240
Counties Served: Jim Hogg, Starr, Webb, Zapata
[pic]
Longview
Community Healthcore 800-832-1009
Counties Served: Bowie, Cass, Gregg, Harrison, Marion, Panola, Red River, Rusk, Upshur
[pic]
Lubbock
Lubbock Regional MHMR Center
806-740-1414
Counties Served: Cochran, Crosby, Hockley, Lubbock, Lynn
[pic]
Lufkin
Burke Center
800-392-8343
Counties Served: Angelina, Houston, Jasper, Nacogdoches, Newton, Polk, Sabine, San Augustine, San Jacinto, Shelby, Trinity, Tyler
[pic]
Lytle
Camino Real Community MHMR Center 800-543-5750
Counties Served: Atascosa, Dimmit, Frio, Karnes, La Salle, Maverick, McMullen, Wilson, Zavala
[pic]
McKinney
LifePath Systems
866-260-8000
Counties Served: Collin
[pic]
Midland
Permian Basin Community Centers for MHMR 432-570-3300
Counties Served: Brewster, Culberson, Ector, Hudspeth, Jeff Davis, Midland, Pecos, Presidio
[pic]
Plainview
Central Plains Center
800-687-1300
Counties Served: Bailey, Briscoe, Castro, Floyd, Hale, Lamb, Motley, Parmer, Swisher
[pic]
Portland
Coastal Plains Community MHMR Center
800-841-6467
Counties Served: Aransas, Bee, Brooks, Duval, Jim Wells, Kenedy, Kleberg, Live Oak, San Patricio
[pic]
Rosenberg
Texana Center
800-633-5686
Counties Served: Austin, Colorado, Fort Bend, Matagorda, Waller, Wharton
[pic]
Round Rock
Bluebonnet Trails Community MHMR Center 800-841-1255
Counties Served: Bastrop, Burnet, Caldwell, Fayette, Gonzales, Guadalupe, Lee, Williamson
[pic]
San Angelo
MHMR Services for the Concho Valley
325-653-5933
Counties Served: Coke, Concho, Crockett, Irion, Reagan, Sterling, Tom Green
[pic]
San Antonio
The Center for Healthcare Services
800-316-9241 / 210-223-7233
Counties Served: Bexar
[pic]
Sherman
MHMR Services of Texoma
877-277-2226
Counties Served: Cooke, Fannin, Grayson
[pic]
Stephenville
Pecan Valley MHMR Region
800-772-5987
Counties Served: Erath, Hood, Johnson, Palo Pinto, Parker, Somervell
[pic]
Temple
Central Counties Center for MHMR 800-888-4036
Counties Served: Bell, Coryell, Hamilton, Lampasas, Milam
[pic]
Terrell
Lakes Regional MHMR Center
800-443-1831
Counties Served: Camp, Delta, Ellis, Franklin, Hopkins, Hunt, Kaufman, Lamar, Morris, Navarro, Rockwall, Titus
[pic]
Tyler
Andrews Center
877-934-2131
Counties Served: Henderson, Rains, Smith, Van Zandt, Wood
[pic]
Victoria
Gulf Bend MHMR Center 877-723-3422
Counties Served: Calhoun, DeWitt, Goliad, Jackson, Lavaca, Refugio, Victoria
[pic]
Waco
Heart of Texas Region MHMR Center
254-752-3451 / 254-776-1101
Counties Served: Bosque, Falls, Freestone, Hill, Limestone, McLennan
[pic]
Wichita Falls
Helen Farabee Regional MHMR Centers
800-621-8504
Counties Served: Archer, Baylor, Childress, Clay, Cottle, Dickens, Foard, Hardeman, Haskell, Jack, King, Knox, Montague, Stonewall, Throckmorton, Wichita, Wilbarger, Wise, Young
APPENDIX E: HEALTH AND HUMAN SERVICES REGIONS
[pic]
Appendix E: Health and Human Services Region Codes - Alphabetical by County
|County Name |HHS Region |County Name |HHS Region |County Name |HHS Region |
| |Code | |Code | |Code |
|Anderson County |4 |Coleman County |2 |Gaines County |9 |
|Andrews County |9 |Collin County |3 |Galveston County |6 |
|Angelina County |5 |Collingsworth County |1 |Garza County |1 |
|Aransas County |11 |Colorado County |6 |Gillespie County |8 |
|Archer County |2 |Comal County |8 |Glasscock County |9 |
|Armstrong County |1 |Comanche County |2 |Goliad County |8 |
|Atascosa County |8 |Concho County |9 |Gonzales County |8 |
|Austin County |6 |Cooke County |3 |Gray County |1 |
|Bailey County |1 |Coryell County |7 |Grayson County |3 |
|Bandera County |8 |Cottle County |2 |Gregg County |4 |
|Bastrop County |7 |Crane County |9 |Grimes County |7 |
|Baylor County |2 |Crockett County |9 |Guadalupe County |8 |
|Bee County |11 |Crosby County |1 |Hale County |1 |
|Bell County |7 |Culberson County |10 |Hall County |1 |
|Bexar County |8 |Dallam County |1 |Hamilton County |7 |
|Blanco County |7 |Dallas County |3 |Hansford County |1 |
|Borden County |9 |Dawson County |9 |Hardeman County |2 |
|Bosque County |7 |Deaf Smith County |1 |Hardin County |5 |
|Bowie County |4 |Delta County |4 |Harris County |6 |
|Brazoria County |6 |Denton County |3 |Harrison County |4 |
|Brazos County |7 |De Witt County |8 |Hartley County |1 |
|Brewster County |10 |Dickens County |1 |Haskell County |2 |
|Briscoe County |1 |Dimmit County |8 |Hays County |7 |
|Brooks County |11 |Donley County |1 |Hemphill County |1 |
|Brown County |2 |Duval County |11 |Henderson County |4 |
|Burleson County |7 |Eastland County |2 |Hidalgo County |11 |
|Burnet County |7 |Ector County |9 |Hill County |7 |
|Caldwell County |7 |Edwards County |8 |Hockley County |1 |
|Calhoun County |8 |Ellis County |3 |Hood County |3 |
|Callahan County |2 |El Paso County |10 |Hopkins County |4 |
|Cameron County |11 |Erath County |3 |Houston County |5 |
|Camp County |4 |Falls County |7 |Howard County |9 |
|Carson County |1 |Fannin County |3 |Hudspeth County |10 |
|Cass County |4 |Fayette County |7 |Hunt County |3 |
|Castro County |1 |Fisher County |2 |Hutchinson County |1 |
|Chambers County |6 |Floyd County |1 |Irion County |9 |
|Cherokee County |4 |Foard County |2 |Jack County |2 |
|Childress County |1 |Fort Bend County |6 |Jackson County |8 |
|Clay County |2 |Franklin County |4 |Jasper County |5 |
|Cochran County |1 |Freestone County |7 |Jeff Davis County |10 |
|Coke County |9 |Frio County |8 |Jefferson County |5 |
|County Name |HHS Region |County Name |HHS Region |County Name |HHS Region |
| |Code | |Code | |Code |
|Jim Hogg County |11 |Midland County |9 |San Saba County |7 |
|Jim Wells County |11 |Milam County |7 |Schleicher County |9 |
|Johnson County |3 |Mills County |7 |Scurry County |2 |
|Jones County |2 |Mitchell County |2 |Shackelford County |2 |
|Karnes County |8 |Montague County |2 |Shelby County |5 |
|Kaufman County |3 |Montgomery County |6 |Sherman County |1 |
|Kendall County |8 |Moore County |1 |Smith County |4 |
|Kenedy County |11 |Morris County |4 |Somervell County |3 |
|Kent County |2 |Motley County |1 |Starr County |11 |
|Kerr County |8 |Nacogdoches County |5 |Stephens County |2 |
|Kimble County |9 |Navarro County |3 |Sterling County |9 |
|King County |1 |Newton County |5 |Stonewall County |2 |
|Kinney County |8 |Nolan County |2 |Sutton County |9 |
|Kleberg County |11 |Nueces County |11 |Swisher County |1 |
|Knox County |2 |Ochiltree County |1 |Tarrant County |3 |
|Lamar County |4 |Oldham County |1 |Taylor County |2 |
|Lamb County |1 |Orange County |5 |Terrell County |9 |
|Lampasas County |7 |Palo Pinto County |3 |Terry County |1 |
|La Salle County |8 |Panola County |4 |Throckmorton County |2 |
|Lavaca County |8 |Parker County |3 |Titus County |4 |
|Lee County |7 |Parmer County |1 |Tom Green County |9 |
|Leon County |7 |Pecos County |9 |Travis County |7 |
|Liberty County |6 |Polk County |5 |Trinity County |5 |
|Limestone County |7 |Potter County |1 |Tyler County |5 |
|Lipscomb County |1 |Presidio County |10 |Upshur County |4 |
|Live Oak County |11 |Rains County |4 |Upton County |9 |
|Llano County |7 |Randall County |1 |Uvalde County |8 |
|Loving County |9 |Reagan County |9 |Val Verde County |8 |
|Lubbock County |1 |Real County |8 |Van Zandt County |4 |
|Lynn County |1 |Red River County |4 |Victoria County |8 |
|McCulloch County |9 |Reeves County |9 |Walker County |6 |
|McLennan County |7 |Refugio County |11 |Waller County |6 |
|McMullen County |11 |Roberts County |1 |Ward County |9 |
|Madison County |7 |Robertson County |7 |Washington County |7 |
|Marion County |4 |Rockwall County |3 |Webb County |11 |
|Martin County |9 |Runnels County |2 |Wharton County |6 |
|Mason County |9 |Rusk County |4 |Wheeler County |1 |
|Matagorda County |6 |Sabine County |5 |Wichita County |2 |
|Maverick County |8 |San Augustine County |5 |Wilbarger County |2 |
|Medina County |8 |San Jacinto County |5 |Willacy County |11 |
|Menard County |9 |San Patricio County |11 |Williamson County |7 |
|County Name |HHS Region |
| |Code |
|Wilson County |8 |
|Winkler County |9 |
|Wise County |3 |
|Wood County |4 |
|Yoakum County |1 |
|Young County |2 |
|Zapata County |11 |
|Zavala County |8 |
APPENDIX F: GENERAL AFFIRMATIONS
Located in Package 3
APPENDIX G: NON-EXCLUSIVE LIST OF APPLICABLE LAWS
Located in Package 4
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