Texas Health and Human Services
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Open Enrollment
For
Home and Community Based Services—Adult Mental Health
Recovery Management Entity
Health and Human Services Commission
Procurement Number: HHS0000074
Enrollment Period Opens: 12/18/2014
Enrollment Period Closes: 08/31/2021
CPA Class/Item Code:
952/62
Addendum 6 – August 4, 2020
Addendum 5 – March 9, 2020
Addendum 4 – May 31, 2019
Addendum 3 – March 3, 2019
Addendum 2 – January 13, 2017
Addendum 1 – January 8, 2016
TABLE OF CONTENTS
I. INTRODUCTION AND DEFINITIONS 4
A. Introduction 4
B. Definitions 5
II. LIMITATIONS 10
III. FUNDING AND TERM 11
A. Use of Funds 11
B. Funding Obligation 11
C. Term of Contract 11
IV. ELIGIBLE RESPONDENTS 12
A. Eligibility Requirements and Affirmations 12
B. Required Activities 16
V. PROGRAM INFORMATION 19
A. Scope of Work 19
B. Legal Authority 20
C. Program Requirements 20
D. Method of Payment 21
VI. PROCUREMENT AND ADMINISTRATIVE REQUIREMENTS 22
A. OE Point of Contact 22
C. Evaluation Process 22
D. Rejection of Enrollment Applications 24
E. Right to Amend OE or Withdraw OE 25
F. Authority to Bind SYSTEM AGENCY 25
G. Financial and Administrative Requirements 25
H. Contract Information 26
I. Contracting with Subcontractors 26
VII. APPLICATION INSTRUCTIONS AND CRITERIA FOR ACCEPTANCE 27
VIII. BLANK FORMS AND INSTRUCTIONS 28
FORM A: FACE PAGE 29
FORM B: Open Enrollment Application Checklist 32
FORM C: Contact Person Information Form 33
FORM D: BOARD MEMBER INFORMATION 34
FORM E: HOUSING AND ENTITLEMENT ATTESTATION 35
Form F: Organizational Overview, Philosophy, or Mission Statement 36
Form G: Organizational Chart/Structure 37
Form H: Policies and Procedures 38
Form I: Job Description for the HCBS-AMH Recovery Management Position 39
FORM J: Proof of General Liability Insurance 40
FORM K: Organization Brochure or Biographical Information 41
IX. APPENDICES 42
APPENDIX A: DSHS ASSURANCES AND CERTIFICATIONS 42
APPENDIX B: GENERAL PROVISIONS 49
APPENDIX C: STANDARDIZED RATES OR APPROVED COSTS 50
APPENDIX D: LMHA SERVICE REGIONS BY COUNTY 51
1 I. INTRODUCTION AND DEFINITIONS
2 A. Introduction
The Health and Human Services Commission (“SYSTEM AGENCY”) Home and Community Based Services-Adult Mental Health (HCBS-AMH) Services Program announces this notice of Open Enrollment (OE) requesting applications to enter into a contract with SYSTEM AGENCY. Respondents are hereby notified that the HCBS-AMH Services Program and all functions associated with the HCBS-AMH Services Program have been transferred by the Department of State Health Services to SYSTEM AGENCY with all rights, responsibilities and obligations thereto, as provided in Texas Government Code, Section 531.0201.
The contingency contract will require the contractor to provide HCBS-AMH Recovery Management services to adults with a diagnosis of serious mental illness and have a history of at least one of the following additional criteria:
1. Long-term psychiatric hospitalization(s);
2. Frequent arrests and psychiatric crisis;
3. Frequent emergency department visits and psychiatric crisis.
The contingency contract will fund Contractor to provide recovery management services for seriously and persistently mentally ill adults enrolled in the HCBS-AMH program. Contractors will bill SYSTEM AGENCY for all clinical services provided including the development, coordination and monitoring of services in line with a person-centered recovery model.
The contingency contract will fund HCBS-AMH Recovery Management services for individuals enrolled in the HCBS-AMH program by SYSTEM AGENCY. Contractor shall ensure the provision of HCBS-AMH Recovery Management services listed in Service Codes, Descriptions, and Provider Qualifications found in the HCBS-AMH Provider Manual and HCBS-AMH Billing Guidelines which are available online at .
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 SYSTEM AGENCY 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.
SYSTEM AGENCY recommends Respondents seek technical assistance in completing this OE and HCBS-AMH program implementation support via The University of Texas Health Science Center- San Antonio (UTHSCSA). For more details on the specific assistance available, email Dr. Matt Brown at brownma@uthscsa.edu.
Dr. Matt Brown is a subject matter expert on the HCBS-AMH OE document and process, and can provide comprehensive, no-cost technical assistance to OE Respondents. Dr. Matt Brown and UTHSCSA are prepared to assist Respondents with completing all aspects of the OE.
Respondents that are unsuccessful in three attempts to submit a complete and acceptable application will be restricted from reapplying for 365 days from the date of the last rejected application.
The enrollment period begins December 18, 2014 and will remain open through August 31, 2020. Respondents deemed qualified to provide services shall be awarded a Contingency Contract which shall be effective on the day of execution through 8/31/2022. SYSTEM AGENCY may, at its sole discretion, extend the closing date of this OE. As stated in Sec. II, SYSTEM AGENCY may also, at its sole discretion, withdraw this OE before the stated date the enrollment period ends.
READ ALL MATERIALS BEFORE RESPONDING TO THIS OPEN ENROLLMENT.
3 B. Definitions
Standard Definitions
Appendix – Additional information and/or forms that are located at the end of this document, which are part of this solicitation document.
Budget – A financial schedule documented in the contract that describes how funds will be used and/or describes the basis for reimbursement for the provision of contracted services. Types of budget may include categorical (line item), fee for service, or lump sum payable upon receipt of a product or deliverable.
Budget Period – The duration of the budget (stated in the number of months the contract will reflect from begin date to end date of the term of the contract). Each renewal will have its own budget period.
Center for Medicaid/Medicare Services – is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works collaboratively with state governments to administer Medicaid.
Clinical Management for Behavioral Health Services – a web-based clinical record keeping system for state-contracted community mental health and substance abuse service providers.
Contingency Contract – Also called a “contract” in this OE, a written agreement referring to promises or agreements for which the law establishes enforceable duties and remedies between a minimum of two parties and which is contingent on one or more factors. A SYSTEM AGENCY contract is assembled using a core contract (base), one of more program attachments, and other required exhibits (general provisions, etc.).
Contract Term – The period of time during which the contract or program attachment will be effective from execution date to end, or renewal date.
Cost Reimbursement – A payment mechanism in which funds are provided to carry out approved contract activities. Reimbursement is based on actual allowable costs incurred that comply with contractual requirements.
Debarment – An exclusion from contracting or subcontracting with state agencies on the basis of cause set forth in Title 34, Texas Administrative Code, §20.105 et seq.
Deliverables – Goods or services contracted for delivery or performance.
Due Date – Established deadline for submission of a document or deliverable.
Effective Date – The date the contract term is effective.
Entity – A person, business, organization, or LLC that submits a response to 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 SYSTEM AGENCY to describe the person, business, organization, or LLC that responds to a solicitation.
Fee-for-Service – Payment mechanism for services that are reimbursed on an agreed rate per unit of service.
Fully Executed – A contract that is signed by all of the parties to form a legally binding contractual relationship. Activities under the contract will not begin and payments to the contractor will not be made until the contract is fully executed.
Individual Recovery Plan – A written, individualized plan, developed in consultation with the individual and LAR, if applicable, which identifies the necessary HCBS to be provided to the individual and also serves as the treatment plan or recovery plan.
Medicaid Management Information System – automated management and control system for Medicaid payments.
Procurement and Contracting Services – The division within SYSTEM AGENCY that provides direction and support of purchasing, contracting and HUB services. PCS oversees, coordinates, and assists the Program with procurement needs, issues open enrollments and competitive procurements. PCS maintains the official contract file from procurement to contract closeout
Program – Depending upon the context, either a coordinated group of activities carried out by SYSTEM AGENCY, as authorized by state or federal law, for a specific purpose (“program”) or SYSTEM AGENCY staff located in a program, region, or hospital that identify and request procurement needs (“Program”). The Program partners with PCS on procurements.
Program Attachment – An attachment to the core contract that provides details for a particular statement of work to be performed under the contract such as services to be delivered, performance measures or deliverables, funding, and reporting requirements. There may be multiple program attachments associated with a core contract. Program Attachment is sometimes called a contract attachment.
Project – All work to be performed as a result of a contract or solicitation
Provider of Last Resort – An entity that is the only willing and qualified entity in a geographic area the individual chooses to provide the service.
Recovery Management at an Intensive Level – Intensive services provided by the Recovery Manager which includes a minimum of three visits per week to the HCBS-AMH participant, with one of these visits being in the participant’s home. These services occur during the first three months of service provision, crisis situations, and re-engagement/discharge or transfer planning.
Recovery Management Entity – An entity that directly employs individual Recovery Manager(s).
Recovery Manager – A person providing the HCBS-AMH Recovery Management service. HCBS-AMH Recovery Management services assist individuals in gaining access to needed Medicaid state plan and HCBS-AMH services, as well as medical, social, educational, and other resources. Recovery Managers are responsible for monitoring the provisions of services included in the Individual Recovery Plan (IRP) to ensure that the individual’s needs, preferences, health and welfare are promoted.
Respondent – A person or entity that submits a response to a solicitation. For purposes of this document, “respondent” is intended to include such phrases as “offeror”, “applicant”, “bidder”, “responder”, or other similar terminology employed by SYSTEM AGENCY to describe the person or entity that responds to a solicitation.
Scope of Work – A description of the services and/or goods, if any, for each service type, to be obtained as a result of this solicitation.
Service Area – The geographical area that a Respondent will serve which is the same as a Local Mental Health Authority’s service area.
Solicitation – The process of notifying prospective contractors of an opportunity to provide goods or services to the state (e.g., this OE).
Special Provisions – Modifications or additions to the General Provisions for a funded program activity, which are usually customized for the Program’s requirements and contain provisions specific to the Program Attachment.
Statement of Work – The description of services and/or goods to be delivered by the SYSTEM AGENCY contractor specifying the type, level and quality of service, that directly relate to program objectives.
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 or by the IRS.
Unit Rate – Payment mechanism for services that are reimbursed at a set rate per unit of service; for example, treatment services at a prescribed rate per hour. Also known as fee-for-service. Rates are available through the SYSTEM AGENCY website at .
Vendor – A type of contractor or subcontractor that provides services, and goods, if any, that assist in, but are not the primary means of, carrying out the SYSTEM AGENCY-funded program. Under a vendor contract, the vendor will have few if any 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 SYSTEM AGENCY-funded clients in the same manner the vendor would deliver those services to its non-SYSTEM AGENCY-funded clients.
A vendor contractor generally has most of the following characteristics: a) provides goods and services within normal business operations, b) provides similar goods and services to many different purchasers, c) operates in a competitive environment, d) is not subject to compliance requirements of the federal or state program, e) provides goods and services that are ancillary to the operation of the program. Note: Characteristics a, b, c, and d do not apply to vendor contractors that are universities.
Vendor Identification Number (Vendor ID No. 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 + three digit mail code. The VIN includes all the numbers in the TIN (defined above), including a three digit mail code for a total of 14 digits.
Work Plan – A plan that describes how services will be delivered to the eligible population and includes specifics such as what types of clients will be served, who will be responsible for the work, timelines for completion of activities, and how services will be evaluated when complete. To be an enforceable part of the contract, details from the work plan must be approved by SYSTEM AGENCY and incorporated in the contract.
HCBS-AMH Definitions
HCBS-AMH program definitions can be found in the HCBS-AMH Provider Manual, available online at .
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1 II. LIMITATIONS
Issuance of this OE in no way constitutes a commitment by SYSTEM AGENCY or the State of Texas to execute a contract or to pay any costs incurred by any Respondent who may submit an enrollment application.
The resulting contingency contract will be subject to the availability of state and federal funds and the need for HCBS-AMH services. Contingency contracts awarded under this OE and any anticipated contract renewals are contingent upon the continued availability of funding. SYSTEM AGENCY reserves the right to alter, amend or withdraw this OE at any time prior to the execution of a contingency contract. If a contingency contract has been fully executed and this OE is altered, amended, or withdrawn, SYSTEM AGENCY and contractor’s obligations and rights will be determined in accordance with the provisions of the contract.
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2 III. FUNDING AND TERM
4 A. Use of Funds
Contingency contracts will be awarded for the purpose specifically defined in this OE. SYSTEM AGENCY will review applications in the order in which they are received. Medicaid rates established by SYSTEM AGENCY will be the payment methodology for services provided by a contractor under this contingency contract.
SYSTEM AGENCY, at its sole discretion, may adjust the funding amount of a Program Attachment based on performance measures, outcome measures, waitlist, and/or other criteria determined by SYSTEM AGENCY, and contingent on availability of funds allocated for the adjustments SYSTEM AGENCY may implement an alternative reimbursement methodology using the rates set forth herein (or using the rates that exist at the time a contract is executed). This alternative methodology may include the use of a case rate based on expected lengths of stay.
SYSTEM AGENCY does not guarantee a minimum amount to be paid to a contractor pursuant to a contingency contract awarded through this OE.
5 B. Funding Obligation
This Contract is contingent upon the availability of funding. If funds become unavailable through lack of appropriations, budget cuts, transfer of funds between programs or health and human services agencies, amendment of the Appropriations Act, Health and Human Services agency consolidation, or any other disruptions of current appropriated funding for this Contract, SYSTEM AGENCY may restrict, reduce or terminate funding under this Contract. Notice of any restriction or reduction shall include instructions and detailed information on how SYSTEM AGENCY shall fund the services and/or goods to be procured with the restricted or reduced funds.
6 C. Term of Contract
Contingency contracts awarded under this OE will be effective on the date of execution through August 31, 2022.
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1 IV. ELIGIBLE RESPONDENTS
7 A. Eligibility Requirements and Affirmations
Eligible respondents include organizations, business, LLC or individuals with the capacity to meet requirements to provide HCBS-AMH Recovery Management Services. Eligible respondent must comply with the criteria listed below. For further information refer to the HCBS-AMH Provider Manual at .
Minimum Requirements for All Direct Service Providers of HCBS-AMH Recovery Management:
1. Have at least 2 years of experience working with people with severe mental illness;
2. Have a master’s degree in human services or a related field.
3. Prior to receiving referrals for the provision of HCBS-AMH services, Respondent must be authorized as an active Medicaid Provider.
4. 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.
5. Respondent must have a Texas address. A post office box may be used when the enrollment application is submitted, but the respondent must conduct business at a physical location in the service region or within 30 miles of an adjacent service region prior to the date that the contract is awarded. This physical location must be zoned to conduct business, be compliant with property agreements, and be obtained prior to the site review as well as prior to date the contract is awarded. If respondent’s business address is their home respondent shall attach proof that the building is approved to be zoned for business or if leased that the building owner approves the space to be used for business purposes.
6. Respondent 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. Respondent’s staff members, including the executive director, must not serve as voting members on their employer’s governing board.
9. Respondent shall have a HIPPA compliant encrypted e-mail extension that is exclusively associated with the respondent’s organization and have capacity to assign employees an e-mail address with the exclusive e-mail extension.
10. Respondent shall provide SYSTEM AGENCY, upon request, with the personnel files of any or all HCBS-AMH staff (including administration, owners and board members) prior to the commencement of HCBS-AMH services and at the request of SYSTEM AGENCY. Personnel files shall include:
a. Credentialing (including verification of licensure, qualifications, training requirements, certification records for employees; and
b. Federal Criminal Background Check and fingerprints; and
c. Registry Clearances to include but not limited to Nurse Aid Registry and Employee Misconduct Registry.
11. Respondent and all administrative staff shall complete HCBS-AMH Pre-application modules located at the following website: prior to completion of the OE application. Respondents shall submit Pre-application certificates with the OE application to verify completion of all HCBS-AMH Pre-application modules.
12. 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.
13. A respondent is not considered eligible to contract with SYSTEM AGENCY if a name match is found on any of the following lists:
a. The System for Award Management (SAM) is an official U.S. Government system that consolidated the capabilities of CCR/Fed Reg, ORCA and EPLS. If the Respondent is listed under the Active Excluded subsection of the SAM, they are excluded. Search the federal excluded list at the following website ; and
b. Texas Comptroller of Public Accounts Debarment List located at
14. Respondent must have established organizational policies and procedures that comply with HCBS-AMH standards. Topics include, but are not limited to (See HCBS-AMH Provider Manual at located at for guidance regarding minimum standards):
a. Confidentiality and retention of client records and progress notes;
b. Provision of services / coordination of care (including routine and emergency appointment availability, access to Recovery Manager or alternate contact person 24 hours a day, 7 days a week, 365 days a year, and assurance that all HCBS-AMH Recovery Management services and HCBS-AMH provider services will be available to individuals in each service area. This includes notification of SYSTEM AGENCY when/if HCBS-AMH Recovery Management services or other HCBS-AMH provider services are unavailable for any period of time);
c. Quality management plan; to include diagnosis of issues and resolution
d. Utilization management;
e. Determination of respondent’s capacity to serve individuals (See section 2110 of the HCBS-AMH Provider manual)
f. Housing and placement policies and procedures (monitoring and tracking placement, expansion of community housing relationship plan, and other procedures identified on Form E);
g. Compliance with 1915(i) federal regulations, including settings requirements for Provider owned and operating settings;
h. Managing Conflicts of Interests if applying to be both Recovery Manager and Provider Agency (include organizational chart that clearly defines administrative separation between Recovery Manager and Provider functions; audit process for managing conflicts of interest; employee trainings and attestation statement; reporting conflicts of interest to SYSTEM AGENCY such as change in administrative structure, billing practice, responsible party for invoice submission).
i. Personnel recordkeeping / management;
j. Critical incident reporting;
k. Personnel and client safety (behavior management procedures restraint procedures: Including but not limited to: TAC Title 25, Part 1, Chapter 415, Subchapter F), suicide precaution/ prevention procedures);
l. Medication safety;
m. Payment of employees;
n. Process to submit reports and billing invoices to SYSTEM AGENCY (including verification of the individual’s Medicaid for a billing period);
o. Medicaid fair hearing;
p. Consumer rights and grievances
q. Reporting of abuse, neglect, and exploitation
r. Critical Incidents
s. Transfer of individuals to another HCBS-AMH Provider; and
t. Discharge of individuals from the HCBS-AMH program.
15. Respondent affirms they are not related by blood or marriage to an individual enrolled in HCBS-AMH services.
16. Respondent affirms they are not empowered to make financial or health-related decisions on behalf of an individual enrolled in the HCBS-AMH program.
17. Respondent affirms they have not violated federal law in connection with any contract awarded by the federal government for relief, recovery or reconstruction efforts as a result of Hurricanes Katrina or Rita or any other disaster occurring after September 25, 2005, the respondent is ineligible to receive a Provider Agreement.
18. A respondent affirms they have not had a contract or Provider Agreement suspended or terminated, or has surrendered its license, or has had its license suspended or revoked by any local, state or federal department or agency or non-profit respondent.
19. All respondents must disclose to SYSTEM AGENCY all pending or threatened litigation.
20. Respondent must affirm identification to SYSTEM AGENCY whether any person who has an ownership, controlling or vested interest in the organization to include but not limited to an employee, subcontractor, volunteer or intern has pending criminal charges, is monitored by community supervision (probation or parole) has received deferred adjudication or has been convicted of a criminal offense in accordance with 25 TAC §414, Subchapter K.
21. Respondent affirm they will comply with Human Resources Code, Section 48.252, requiring a provider to
a. Cooperate completely with an investigation of alleged abuse, neglect, or exploitation conducted by the Department of Family and Protective Services.
b. Provide complete access to the Department of Family and Protective Services during an investigation to:
i. All sites owned, operated, or controlled by the provider; and
ii. Clients and client records.
22. Local Mental Health Authorities shall affirm they will comply with the Texas Administrative Code, Chapter 414, Subchapter L. This includes, but is not limited to:
a. Amending their contracts to ensure contractor’s compliance with this subchapter.
b. Implementing policies and procedures addressing disciplinary and other action in conformed cases of abuse, neglect, and exploitation involving employees and agents, in accordance with Section 414.557.
c. Ensuring that a Client Abuse and Neglect Reporting form (AN-1-A) is completed within 14 calendar days of the receipt of the investigative report from the Department of Family and Protective Services or a decision made after review of appeal using the CANRS Definitions and the CANRS Classification, when the perpetrator or alleged perpetrator is an employee or agent of the Local Mental Health Authority, community center, or contractor, or if the perpetrator is unknown.
d. Ensuring, within one working day after completion of the AN-1-A form that:
i. The information contained in the completed AN-1-A form is entered into the Client Abuse Neglect Reporting System (CANRS); or if access to CANRS is unavailable, a copy of the completed AN-1-A form is forwarded for data entry to the Office of Consumer Services and Rights Protection-Ombudsman, P.O. Box 12668, Austin, TX 78711-2668.
23. If Respondent is applying for both the Recovery Management OE and the HCBS-AMH Provider OE, Respondent affirms that recovery management decisions will not be subject to influence or revision by those providing or administering other HCBS-AMH services.
24. Respondent must have general liability insurance at a minimum of $3Million aggregate (Form J).
25. All documents submitted must be numbered in numerical sequence in the lower right corner. Any additions to the original submission may be added, but the application must be renumbered to ensure the final packet is sequentially numbered and the entire packet resubmitted.
26. If a contingency contract has been fully executed and the Respondent requests to contract to serve additional service region(s) or additional target population(s), Respondent will comply with expansion practices as outlined in the Manual and complete the following:
a. Updated Form-A-Face Page
b. Updated Form-C-Contact Person Information
c. Updated Form G-Organizational Chart
d. Updated Form-J-Proof of General Liability Insurance
e. Updated Form-K-Organizational Brochure or Biographical Information
f. Updated electronic Policy and Procedure Manual from the Respondent to reflect the additional proposed service region(s), target population(s), or programmatic changes due to expansion.
g. Provide addresses to physical locations within the requested expansion service region(s).
i. On site reviews of Respondent offices and residential settings in requested service region(s) designated for individuals enrolled in HCBS-AMH will be conducted at the discretion of SYSTEM AGENCY. Onsite reviews for additional service regions are subject to the terms identified in Section VI.C.4.
8 B. Required Activities
Respondent must provide HCBS-AMH recovery management services and associated activities to individuals enrolled in the HCBS-AMH program directly. Documentation of HCBS-AMH Recovery Management services must be provided to SYSTEM AGENCY upon request. HCBS-AMH Recovery Management services provided by the HCBS-AMH Recovery Manager include but are not limited to the following:
1. Educate and inform the individual enrolled in the HCBS-AMH program about services, the individual recovery planning process, recovery resources, rights, and responsibilities;
2. Obtain and review supporting documentation (assessment data, medical, psychiatric, criminal records) and make recommendations to be used as a guide in the independent recovery process;
3. Coordinate and develop the IRP using a person-centered planning approach which supports the individual enrolled in the HCBS-AMH program in directing and making informed choices according to the individual’s needs and preferences;
4. When applicable, provide pre-transition services (recovery management inside the in-patient psychiatric facility) to maximize the individual enrolled in the HCBS-AMH program’s readiness to transition effectively into the community;
5. When applicable, provide recovery management services inside SYSTEM AGENCY approved facility, which may include a correctional or crisis facility;
6. Collect and provide supporting documentation to be considered by SYSTEM AGENCY in the independent evaluation and reevaluations;
7. Document interactions with individuals and service providers and ensure individual’s documents are kept in secure location to maintain confidentiality;
8. Identify and facilitate services providers and brokers to obtain and integrate services and advocate to resolve issues that impede access to needed services;
9. Develop/pursue resources to support the individual enrolled in the HCBS-AMH program’s recovery goals including non-HCBS Medicaid, Medicare, and/or private insurance or other community resources;
10. Assist the individual enrolled in the HCBS-AMH program in identifying and developing natural supports (family, friends, and other community members) and resources to promote the individual’s recovery;
11. Inform individual enrolled in the HCBS-AMH program of their consumer rights in area of housing, entitlements, and other services provided;
12. Assist individual enrolled in the HCBS-AMH program with fair hearing requests when needed and upon request;
13. Assist individual enrolled in the HCBS-AMH program with applying for and maintaining income source;
14. Connect individual enrolled in the HCBS-AMH program with necessary resources to address legal, immigration and entitlement needs;
15. Actively coordinates with other individuals and/or service providers essential to physical and/or behavioral services for the individual enrolled in HCBS-AMH program (including their MCO) to ensure that other services are integrated and support their recovery goals, health, and welfare;
16. Monitor health, welfare, and safety through regular contacts (visits with the individual enrolled in the HCBS-AMH program, their paid and unpaid supports, and natural supports) at a minimum frequency required by SYSTEM AGENCY;
17. Respond to and assesses emergency situations and incidents and provides appropriate crisis and referrals to respite services to ensure that appropriate actions are taken to protect the health, welfare, and safety of all individuals involved in these incidences;
18. Review service provider documentation and monitors the individual enrolled in the HCBS-AMH’s progress;
19. Initiate and facilitate recovery plan team discussions or meetings when services are not achieving desired outcomes. Outcomes include housing status, employment status, involvement in the criminal justice system, response to treatment and other services, and satisfaction with services;
20. Through the recovery plan monitoring process, solicits input from the individual enrolled in the HCBS-AMH program and/or their family, as appropriate, related to satisfaction with services;
21. Provide linkage to training and counseling for individual enrolled in the HCBS-AMH program family support or unpaid caregivers;
22. Coordinate transportation and communication services to ensure ease of accessibility to services for the individual enrolled in the HCBS-AMH program.
23. Provide referrals and monitoring of pre-vocational, supported employment, and supported education;
24. Coordinate peer support services and linkage to peer support programs, trainings and other resources to help the individual enrolled in the HCBS-AMH program become fully integrated in his/her community of choice;
25. Assist the individual enrolled in the HCBS-AMH program in navigating through transfer of services and discharge planning;
26. In the case of provider of last resort, have policy which keeps the HCBS-AMH Recovery Management role administratively separate from HCBS-AMH provider;
27. Arrange for modifications in services and service delivery, as necessary;
28. Advocate for continuity of services, system flexibility and integration, proper utilization of facilities and resources, accessibility, and beneficiary rights;
29. Participate in any SYSTEM AGENCY-identified activities related to quality oversight and provide reporting as required by SYSTEM AGENCY;
30. Maintain appropriate documentation of all HCBS-AMH Recovery Management services in the format prescribed by SYSTEM AGENCY. Information shall be collected, maintained, and reported by Respondent in accordance with the following specifications:
a. All reports shall be submitted to SYSTEM AGENCY within the time frame and formats, and including subject matter, specified in the contract and by SYSTEM AGENCY Project Director. Respondent shall work closely with SYSTEM AGENCY staff to track the time between report requests and production.
b. Respond within five working days to requests for ad hoc reports by SYSTEM AGENCY.
c. Report critical incidents as defined by SYSTEM AGENCY in writing within 72 hours of incident or notification of the incident and in accordance with SYSTEM AGENCY policy;
31. Maintain appropriate documentation of the administration of all HCBS-AMH Recovery Management services and expenditures as instructed by SYSTEM AGENCY. Respondent shall comply with the roles and responsibilities of the recovery management respondent HCBS-AMH Provider Manual, available online at ;
32. Abide by applicable federal and state laws, regulations, and rules relating to activities listed above;
33. Have a HIPPA compliant encrypted e-mail extension that is exclusively associated with the respondent or the respondent’s organization and have capacity to assign employees an e-mail address with the exclusive e-mail extension for training purposes and submitting reporting data; and
34. Participate in any SYSTEM AGENCY-identified activities related to quality oversight and provide reporting as required by SYSTEM AGENCY.
35. Respondent, at own expense, shall conduct an annual Federal Criminal Background check with fingerprints and Abuse Registry checks for all individuals involved in the administration and provision of HCBS-AMH Recovery Management services to include but not limited to employees, volunteers and interns;
36. Respondent shall provide SYSTEM AGENCY, upon request, with the personnel files of any or all identified HCBS-AMH Recovery Manager and alternate Recovery Manager prior to the commencement of HCBS-AMH services. Personnel files shall include:
a. Credentialing (including verification of licensure, qualifications, training requirements, and certification records for employees;
a. Federal Criminal Background Check with Fingerprints and Abuse Registry Clearances
b. Resume; and
c. W-4 Forms of identified Recovery Managers
37. Respondent shall receive approval from SYSTEM AGENCY on their determined capacity to serve prior to the provision of HCBS-AMH services. (See HCBS-AMH Provider Manual Section 2110 for complete information)
38. Respondent shall affirm they have a history of compliance with the laws relating to the respondent’s business operations and the affected services and whether the respondent is currently in compliance.
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1 V. PROGRAM INFORMATION
9
10 A. Scope of Work
The HCBS-AMH program is designed to provide services that support long term recovery from mental illness. Recovery is not a “cure,” but an on-going process through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Dimensions of personal recovery include better managing one’s physical and mental well-being, attaining stable and safe housing, engaging in meaningful daily life activities to achieve personal goals, forging and cultivating relationships with others in the community, developing a positive sense of identity, and regaining belief in one’s self. The HCBS-AMH program is not time-limited, but available to the individual for as long as they need it. Additional information about the HCBS-AMH program can be accessed at .
A key component in the HCBS-AMH program is HCBS-AMH Recovery Management. HCBS-AMH Recovery Management services include identifying, coordinating and monitoring the provision of HCBS-AMH services.
Individuals enrolled in the HCBS-AMH program will select an approved Contractor to provide HCBS –AMH Recovery Management Services during the enrollment process and may select a different provider of HCBS-AMH Recovery Management services at any time. Once selected, Contractor shall provide HCBS-AMH Recovery Management Services in accordance with applicable state laws, rules and HCBS-AMH requirements. These include but are not limited to applicable federal laws and regulations, including the Code of Federal Regulations (C.F.R.) Title 42, Parts 440, 441, 455 and 456; 25 Texas Administrative Code Chapter 414, and applicable subchapters of 1 Texas Administrative Code Chapter 355; 45 C.F.R. Parts 46, 80, 84, 90 and 91; TAC 412, subchapter C; and TAC 416, subchapter B the laws, rules and regulations cited in the various sections of the HCBS-AMH Provider Manual located at ; and any rules or regulations that are promulgated subsequent to the execution of a contingency contract and that are applicable to Contractor’s provision of HCBS-AMH Recovery Management services under this Open Enrollment. Contractor shall be compensated for HCBS-AMH Recovery Management services based on the Medicaid rates of service established by SYSTEM AGENCY. OE is not limited to this source of funding if other sources become available for this project.
When providing HCBS-AMH Recovery Management Services, the Contractor is responsible for developing the Individual Recovery Plan (IRP) and then coordinating and monitoring the provision of HCBS-AMH services for the individual enrolled in the HCBS-AMH program. The Contractor works in collaboration with the individual enrolled in the HCBS-AMH program to develop the IRP using a Person-Centered Recovery Planning Process. This IRP is based on the needs identified on the individual’s HCBS-AMH Uniform Assessment (UA). HCBS-AMH Recovery Management services must be listed on the individual’s IRP and cannot be provided without SYSTEM AGENCY approval of the IRP. After approval of the IRP, the Contractor will coordinate and monitor the delivery of all HCBS-AMH services identified on the individual’s IRP to ensure the health and wellness of the individual enrolled in the HCBS-AMH program. Contractor is responsible for updating and revising the IRP in the time frames specified by SYSTEM AGENCY.
Additionally, the Contractor providing HCBS-AMH Recovery Management services may not be a Provider of other HCBS-AMH services listed on the individual’s IRP, unless the Contractor is the only willing and qualified entity in a geographic area who the individual chooses to provide the service. Contractor becoming a provider of last resort is contingent upon the Contractor obtaining a separate contract with SYSTEM AGENCY under the HCBS-AMH Provider Agency OE.
Contractor shall comply with SYSTEM AGENCY standards and certification principles and requirements to the extent applicable to the HCBS- AMH Recovery Management services provided under the contract type identified in this contract. Contractor shall also verify that the individual providing HCBS-AMH Recovery Management Services has participated in required training components as identified in the Provider Manual. Contractor shall maintain proof of HCBS-AMH Recovery Management credentialing and training and allow SYSTEM AGENCY to review credentialing files upon request.
11 B. Legal Authority
SYSTEM AGENCY 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). SYSTEM AGENCY, as the Texas Medicaid Agency, delegated administration of the HCBS-AMH Program to SYSTEM AGENCY as authorized by Texas Government Code §531.0055.
12 C. Program Requirements
Contractors are required to conduct Project activities in accordance with federal and state laws prohibiting discrimination. Guidance for adhering to non-discrimination requirements can be found on the SYSTEM AGENCY Civil Rights Office website at:
Upon request, a contractor must provide the SYSTEM AGENCY’s Civil Rights Office with copies of all the contractor’s civil rights policies and procedures. Contractors must notify SYSTEM AGENCY’s Civil Rights Office of any civil rights complaints received relating to performance under the contract no more than 10 calendar days after receipt of the complaint. Notice must be directed to:
HHSC Civil Rights Office
701 W. 51st Street, Mail Code W206
Austin, TX 78751
Phone Toll Free (888) 388-6332
Phone: (512) 438-4313TTY
Toll Free (877) 432-7232
Fax: (512) 438-5885
Contractors shall ensure that its policies do not have the effect of excluding or limiting the participation of persons in the contractor’s programs, benefits or activities on the basis of national origin, and must take reasonable steps to provide services and information, both orally and in writing, in appropriate languages other than English, in order to ensure that persons with limited English proficiency are effectively informed and can have meaningful access to programs, benefits, and activities.
Contractors must comply with Executive Order 13279, and its implementing regulations at 45 CFR Part 87 or 7 CFR Part 16, which provide that any organization that participates in programs funded by direct financial assistance from the U.S. Dept. of Agriculture or U.S. Dept. of Health and Human Services must not, in providing services, discriminate against a program beneficiary or prospective program beneficiary on the basis of religion or religious belief.
Contractors are required to conduct Project activities in accordance with the most recent DSHS Standards for Public Health Clinic Services
Contractors may obtain a copy of the most recent DSHS Standards for Public Health Clinic Services which is posted on the SYSTEM AGENCY website at:
.
SYSTEM AGENCY reserves the right to modify the Statement of Work of the contract and to incorporate Special Provisions into contracts awarded under this OE.
SYSTEM AGENCY reserves the right to perform a Quality Management review at SYSTEM AGENCY’s sole discretion.
13 D. Method of Payment
When a contingency contract is activated, Contractor shall submit invoices to SYSTEM AGENCY. SYSTEM AGENCY will reimburse Contractor for HCBS-AMH Recovery Management services provided on a Medicaid rate structure. Rates are available through SYSTEM AGENCY’s website at .
Reimbursement shall be provided by SYSTEM AGENCY to Contractor in accordance with the provisions stated in the contingency contract. Respondent shall request payment using the invoice process described in the contract to request reimbursement of the required services/deliverables. Acceptable supporting documentation for services/deliverables shall be included within the invoice.
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1 VI. PROCUREMENT AND ADMINISTRATIVE REQUIREMENTS
14 A. OE Point of Contact
For purposes of submitting content questions concerning this OE, the only contact is the Mental Health Contract Management Unit unless otherwise delegated by the OE Point of Contact Director. All communications concerning this OE must be submitted by email to:
OE Point of Contact Email: MHContracts@hhsc.state.tx.us
Ref: OE# HHS0000074
Other employees and representatives of SYSTEM AGENCY 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 to the OE Point of Contact email above.
Questions and answers will be posted on the HHS Opportunities Page as appropriate. System Agency reserves the right to amend answers prior to the open enrollment closing date.
B. Submission
The original enrollment application must be submitted to the OE point of contact at the email address specified in Section VI. A. SYSTEM AGENCY will not accept enrollment applications by mail or fax. Form A requires an original signature. Please scan and make it part of email submittal. Within five (5) business days of submittal, OE point of contact will send an email confirming receipt of application. If you do not receive a confirmation email from the OE point of contact, your application email submittal may have technically failed in transmission. If this has occurred, please contact the OE point of contact to determine the technical problem.
1 C. Evaluation Process
Enrollment applications will be evaluated according to the criteria below. All enrollment applications remain with SYSTEM AGENCY and will not be returned to the respondent.
Enrollment applications are evaluated for eligibility and completeness. The eligibility criteria requirements include the following:
1. The respondent must meet the eligibility criteria, and affirmations, in Section IV. Eligible Respondent.
2. Other screening criteria as follows:
a. FORM A: Face Page. Face Page bears an original signature of the authorized official of the respondent organization;
b. FORM B: Open Enrollment Application Checklist;
c. FORM C: Contact Person Information Form;
d. FORM D: Board Member Information;
e. FORM E: Housing and Entitlement Attestation;
f. FORM F: Organizational Overview, Philosophy, or Mission Statement;
g. FORM G: Organizational Chart/Structure;
h. FORM H: Policies and Procedures; and
i. FORM I: Job Description for HCBS-AMH Recovery Management position
j. FORM J: Proof of General Liability Insurance
k. FORM K: Organization Brochure or Biographical Information
3. After the screening, OE Point of Contact will delegate direct communications to SYSTEM AGENCY program for other evaluation purposes.
4. The respondent may be subject to an Onsite Review which may include the following information, when applicable. Additional information may be requested at the discretion of SYSTEM AGENCY.
a. Information submitted as a part of the OE application;
b. Policies and Procedures Manuals/Operational Handbooks/Guidelines to include the following policies and procedures:
i. Confidentiality and retention of client records and progress notes;
ii. Provision of HCBS-AMH Recovery Management services / coordination of care (including routine and emergency appointment availability, and assurance that all HCBS-AMH Recovery Management services will be available to individuals in each service area. This includes notification of SYSTEM AGENCY when HCBS-AMH recovery management service is unavailable for any period of time);
iii. HCBS-AMH quality management plan;
iv. Utilization management;
v. Determination of respondent’s capacity to serve individuals;
vi. Housing and Entitlement Determination (knowledge of advocacy in areas of housing and entitlements, identified on Form E);
vii. Personnel recordkeeping / management;
viii. Critical incident reporting;
ix. Managing Conflicts of Interest;
x. Personnel, client safety, and crisis planning (behavior management, and restraint, suicide precaution/prevention);
xi. Individual and personnel credentialing and training (including verification of licensure, qualifications, training requirements, and certification records for employees);
xii. Medication safety
xiii. Payment of employees
xiv. Process to submit reports and billing invoices to SYSTEM AGENCY (including verification of the individual’s Medicaid for a billing period);
xv. Medicaid fair hearing;
xvi. Consumer rights and grievances;
xvii. Reporting abuse, neglect, and exploitation;
xviii. Critical incidents;
xix. Transfer of individuals to another HCBS-AMH Entity;
xx. Discharge of individuals from HCBS-AMH;
xxi. Respondent’s licensing, credentialing, and personnel files;
xxii. Organizational or facility environment;
xxiii. Client record keeping practices, by reviewing an existing client record; and
xxiv. Qualifications (education, experience, licensure, certification, training requirements, and registration) of all individuals to provide services as described in the HCBS-AMH Provider Manual, available online at . This includes professional standards and regulations, including malpractice or liability insurance for professional staff.
xxv. Proof of General Liability Insurance
xxvi. Person-Centered Recovery Planning;
xxvii. Provision of clinical supervision best practices; and
xxviii. Knowledge of issues affecting people with severe mental illness and community-based interventions/resources for this population.
On site reviews of Respondent offices and residential setting in requested service region(s) designated for individuals enrolled in HCBS-AMH will be conducted at the discretion of SYSTEM AGENCY. Respondents will provide addresses to physical locations within the requested service region(s).
In conducting the evaluation process, SYSTEM AGENCY at its sole discretion may give 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 SYSTEM AGENCY staff.
2 D. Rejection of Enrollment Applications
1. SYSTEM AGENCY reserves the right to reject any or all enrollment applications and is not liable for any costs incurred by the respondent in the development or submission of the enrollment application.
2. Any attempt by an employee, officer, or agent of the respondent to influence the outcome of SYSTEM AGENCY’s review through contact with any Commissioner or staff member of SYSTEM AGENCY or other Texas Health and Human Services agency will result in rejection of the enrollment application.
3. Any material misrepresentation in an enrollment application submitted to SYSTEM AGENCY will result in rejection of the enrollment application.
4. Enrollment applications may be rejected for failure to meet respondent eligibility criteria or inability to perform required activities.
5. If a Respondent wishes to re-apply for the Open Enrollment after receiving a rejection letter:
a. Respondent is not permitted to re-apply for 6 months from the date of the rejection letter;
b. Respondent must correct the item(s) identified in the rejection letter prior to re-applying: and
c. Respondent must complete a new OE RM Application.
3 E. Right to Amend OE or Withdraw OE
SYSTEM AGENCY reserves the rights to alter, amend, or modify any provisions of this OE or to withdraw this OE at any time prior to the execution of a contract if it is in the best interest of SYSTEM AGENCY and the State of Texas. The decision of SYSTEM AGENCY is administratively final. Amendment or notice of withdrawal of the OE will be posted to the HHS Opportunities Page.
4 F. Authority to Bind SYSTEM AGENCY
For the purposes of this OE, the Commissioner of SYSTEM AGENCY, Assistant Commissioner, Chief Financial Officer or Chief Operating Officer, or the employee designated through commissioner’s directive relating to line of authority (CD-2005.02) to act in place of one of those employees is granted the signature responsibility of that employee are the only individuals who may legally commit SYSTEM AGENCY to the expenditure of public funds under the contract. No costs chargeable to the proposed contract will be reimbursed before the contract is fully executed.
5 G. Financial and Administrative Requirements
General Provisions
1. All contractors under this OE must comply with the FY2015 DSHS Core Vendor General Provisions. The FY2015 Core Vendor General Provisions are located at: .
2. Respondent is not required to return the FY2015 Core Vendor General Provisions or DSHS Assurances and Certifications with their enrollment application. By signing the Form A: Face Page, respondent is agreeing to abide by the referenced General Provisions and DSHS Assurances and Certifications.
6 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 proposal submitted to SYSTEM AGENCY for consideration. SYSTEM AGENCY will accept or reject each proposed exception. SYSTEM AGENCY reserves the right to adjust the funding allocation to contractors pursuant to the terms of the contract.
7 I. Contracting with Subcontractors
The selected respondent may not enter into contracts with subcontractors.
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1
2 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: Board Member Information;
FORM E: Housing and Entitlement Determination;
FORM F: Organizational Overview, Philosophy, or Mission Statement;
FORM G: Organizational Chart/Structure;
FORM H: Policies and Procedures;
FORM I: Job Description for HCBS-AMH Recovery Management position;
FORM J: Proof of General Liability Insurance; and
FORM K: Organization Brochure or Biographical Information.
Respondent shall submit all documents required in this OE. An application must be complete to be considered. SYSTEM AGENCY expressly reserves the right to review and analyze the documentation submitted and determine the respondent’s eligibility for open enrollment.
Respondent Signature. 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.
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3 VIII. BLANK FORMS AND INSTRUCTIONS
Contractor must abide by the requirements contained in the following exhibits, as applicable:
FORM A: Face Page;
FORM B: Open Enrollment Application Checklist;
FORM C: Contact Person Information Form;
FORM D: Board Member Information;
FORM E: Housing and Entitlement Attestation;
FORM F: Organizational Overview, Philosophy, or Mission Statement;
FORM G: Organizational Chart/Structure;
FORM H: Policies and Procedures;
FORM I: Job Description for HCBS-AMH Recovery Management position;
FORM J: Proof of General Liability Insurance; and
FORM K: Organization Brochure or Biographical Information.
APPENDIX A: DSHS Assurance and Certifications
APPENDIX B: General Provisions
APPENDIX C: Standardized Rates or Approved Costs
APPENDIX D: LMHA Service Regions by County
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Health and Human Services Commission
8 FORM A: FACE PAGE
OE # HHS0000074
This form requests basic information about the respondent and project, including the signature of the authorized representative. The face page is the cover page of the proposal and must be completed in its entirety.
|RESPONDENT INFORMATION |
|1) LEGAL BUSINESS NAME: | |
|2) Business MAILING Address Information (include mailing address, street, city, county, state and 9-digit zip |Check if address change | |
|code): | | |
| | |
| | |
| | |
|3) PAYEE Name and Business Mailing Address, including 9-digit zip code |Check if address change | |
|(if different from above): | | |
| | |
| | |
| | |
| | |
|4) |Medicaid Provider Identification Number, if applicable |
|5) Federal Tax ID No. (9-digit), State of Texas Comptroller Vendor ID Number (14-digit) or | |
|Social Security Number (9-digit): | |
|*The respondent acknowledges, understands and agrees that the respondent'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. |
|6) Population(s) Served (check all that apply): |
|Long-Term Hospitalization(LTH) Jail Diversion(JD) Emergency Department (ED) Diversion |
|7) TYPE OF ENTITY (check all that apply): |
| | |City | |Nonprofit Organization* | |Individual |
| | |County | |For Profit Organization* | |Federally Qualified Health Centers |
| | |Other Political Subdivision | |HUB Certified | |State Controlled Institution of Higher Learning |
| | |State Agency | |Community-Based Organization | |Hospital |
| | |Indian Tribe | |Minority Organization | |Private | |
| | | |
|8) SERVICE REGION(S) SERVED BY PROJECT (Enter region(s) and | |
|street address for each service region see Appendix D) | |
|9) Maximum number of individuals the entity can serve: | |
|10) PROJECT CONTACT PERSON |11) FINANCIAL OFFICER |
|Name: | |Name: | |
|Phone: | |Phone: | |
|Fax: | |Fax: | |
|Email: | |Email: | |
|The facts affirmed by me in this proposal are truthful and I warrant the respondent is in compliance with the assurances and certifications |
|contained in APPENDIX B: DSHS Assurances and Certifications. I understand the truthfulness of the facts affirmed herein and the continuing |
|compliance with these requirements are conditions precedent to the award of a contract. This document has been duly authorized by the |
|governing body of the respondent and I (the person signing below) am authorized to represent the respondent. |
|12) AUTHORIZED REPRESENTATIVE |Check if change |13) SIGNATURE OF AUTHORIZED REPRESENTATIVE |
| |Name: | | |
| |Title: | | |
| |Phone: | | |
| |Fax: | | |
| |Email: | | |
| | | | |
| | | |14) |DATE |
GENERAL INSTRUCTIONS FOR THE FACE PAGE
This form provides basic information about the respondent and the proposed project with the Health and Human Services Commission, including the signature of the authorized representative. It is the cover page of the enrollment application and is required to be completed. Signature affirms that the facts contained in the respondent’s response are truthful and that the respondent is in compliance with the assurances and certifications contained in Appendix A: DSHS Assurances and Certifications and acknowledges that continued compliance is a condition for the award of a contract. Please follow the instructions below to complete the face page form and return with the respondent’s enrollment application.
1) LEGAL NAME - Enter the legal name of the respondent.
2) BUSINESS MAILING ADDRESS INFORMATION - Enter the respondent’s complete business street and mailing address, city, county, state, and 9-digit zip code. If respondent’s business address is their home respondent shall attach proof that the building is approved to be zoned for business or if leased that the building owner approves the space to be used for business purposes.
3) PAYEE MAILING ADDRESS - Payee – Entity involved in a contractual relationship with respondent to receive payment for services rendered by respondent and to maintain the accounting records for the contract; i.e., fiscal agent. Enter the PAYEE’s name and mailing address, including 9-digit zip code, if PAYEE is different from the respondent. The PAYEE is the corporation, Respondent or vendor who will be receiving payments.
4) MEDICAID PROVIDER IDENTIFICATION NUMBER- Enter 7-digit Medicaid Provider Identification number if currently a Medicaid Provider.
5) 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
6) POPULATION(S) SERVED - Check the appropriate box(s) for the population(s) that you choose to serve.
A) Long-Term Hospitalization (LTH): Extended in-patient psychiatric hospitalizations as defined by the HCBS-AMH Provider Manual located at .
B) Jail Diversion (JD): Frequent misdemeanor arrests and psychiatric crisis as defined by the HCBS-AMH Provider Manual located at .
C) Emergency Department (ED) Diversion: Frequent utilization of the ED and psychiatric crisis as defined by the HCBS-AMH Provider Manual located at .
7) TYPE OF ENTITY - The type of entity is defined by the Secretary of State and/or the Texas State Comptroller. Check all appropriate boxes that apply.
HUB is defined as a corporation, sole proprietorship, or joint venture formed for the purpose of making a profit in which at least 51% of all classes of the shares of stock or other equitable securities are owned by one or more persons who have been historically underutilized (economically disadvantaged) because of their identification as members of certain groups: Black American, Hispanic American, Asian Pacific American, Native American, and Women. The HUB must be certified by the Texas Building and Procurement Commission or another entity.
MINORITY ORGANIZATION is defined as an organization in which the Board of Directors is made up of 50% racial or ethnic minority members.
If a Non-Profit Corporation or For-Profit Corporation, provide the 10-digit charter number assigned by the Secretary of State.
8) Service REGION(S) TO BE SERVED BY PROJECT - Select the proposed Service Region(s) served by the project. Refer to Appendix D: Service Region by County. For multiple service regions, the RM business office must be within 30 miles of the adjacent service area. List the street address for each service area location: Enter the physical street address (business location) for each service region indicated in line 8. If business location has not yet been secured, list the P.O. Box for each service region. If business address is a home respondent shall attach proof that the building is approved to be zoned for business or if leased that the building owner approves the space to be used for business purposes.
9) MAXIMUM NUMBER OF INDIVIDUALS AN ENTITY CAN SERVE – Enter the maximum number of individuals the entity can serve. (See HCBS-AMH Provider Manual Section 2110)
10) PROJECT CONTACT PERSON - Enter the name, phone, fax, and e-mail address of the person responsible for the proposed project.
11) FINANCIAL OFFICER - Enter the name, phone, fax, and e-mail address of the fiscal person responsible for the proposed project.
12) AUTHORIZED REPRESENTATIVE - Enter the name, title, phone, fax, and e-mail address of the person authorized to represent the respondent. Check the “Check if change” box if the authorized representative is different from previous submission to HHSC.
13) SIGNATURE OF AUTHORIZED REPRESENTATIVE - The person authorized to represent the respondent must sign in this blank.
14) DATE - Enter the date the authorized representative signed this form.
9 FORM B: Open Enrollment Application Checklist
Each Enrollment Application Must Contain the Following Items:
If items not applicable, please mark with N/A
|Document |Check (√), if included |
| | |
|FORM A: HHSC Face Page – Signature Required | |
| | |
|FORM B: Open Enrollment Application Checklist | |
|FORM C: Contact Person Information Form | |
| | |
|FORM D: Board Member Information, If applicable | |
|FORM E: Housing and Entitlement Determination | |
|FORM F: Organizational Overview, Philosophy, or Mission Statement, If applicable | |
|FORM G: Organizational Chart/Structure, If applicable | |
|FORM H: Policies and Procedures | |
|FORM I: Job Description for HCBS-AMH Recovery Management position | |
|FORM J: Proof of General Liability Insurance | |
|FORM K: Organization Brochure or Biographical Information | |
FORM C: Contact Person Information Form
| | |
|Legal Name of Respondent: | |
This form provides information about the appropriate contacts in the Respondent’s organization in addition to those on the FACE PAGE. If any of the following information changes during the term of the contract, please send written notification to the Contract Management Unit.
| |
|Contact: | | |Mailing Address (incl. street, city, county, state, & zip): |
|Title: | | | | |
|Phone: | |Ext. | | | |
|Fax: | | | | |
|E-mail: | | | | |
| |
| |
|Contact: | | |Mailing Address (incl. street, city, county, state, & zip): |
|Title: | | | | |
|Phone: | |Ext. | | | |
|Fax: | | | | |
|E-mail: | | | | |
| |
| |
|Contact: | | |Mailing Address (incl. street, city, county, state, & zip): |
|Title: | | | | |
|Phone: | |Ext. | | | |
|Fax: | | | | |
|E-mail: | | | | |
| |
| |
|Contact: | | |Mailing Address (incl. street, city, county, state, & zip): |
|Title: | | | | |
|Phone: | |Ext. | | | |
|Fax: | | | | |
|E-mail: | | | | |
| |
| |
|Contact: | | |Mailing Address (incl. street, city, county, state, & zip): |
|Title: | | | | |
|Phone: | |Ext. | | | |
|Fax: | | | | |
|E-mail: | | | | |
| |
| |
| |
10 FORM D: BOARD MEMBER INFORMATION
|Organization Name: | |
Board Member Information:
Provide the name, title, home address, home telephone, business telephone and fax number, and email address for all Board Members. Additional lines may be added if needed to submit a complete Board Member list.
|Name: | |
|Board Officer Title: | |
|Board Term: | |
|Home Address: | |
|City, State, ZIP: | |
|Personal Email Address: | |
|Home Telephone #s: | | | |
|Fax Number: | | | |
|Name: | |
|Board Officer Title: | |
|Board Term: | |
|Home Address: | |
|City, State, ZIP: | |
|Personal Email Address: | |
|Home Telephone #s: | | | |
|Fax Number: | | | |
11 FORM E: HOUSING AND ENTITLEMENT ATTESTATION
Recovery Management Respondent shall demonstrate knowledge of coordinating, advocating, and monitoring services in the areas of housing and entitlements. Respondent attests that the answers to these questions are true and accurate.
|1. Does Respondent have experience assisting high need individuals (mentally ill, intellectual development disabilities, medically fragile, |
|physically disabled, ex-offenders) with securing housing and completing the application process? |
|Yes No |
|2. Does Respondent have knowledge about the appeals process for the Local Housing Authority and clear steps to take if the individual is denied |
|housing? |
|Yes No |
|3. Is Respondent aware of the different housing available in their geographic area that meets Code of Federal Regulations Title 42,Chapter |
|IV, Subchapter C, Part 441, Subpart G, §441.710 requirements? |
|Yes No |
|[pic] |
|If not, does Respondent have a plan to expand housing relationships and track placements? |
|Yes No |
|4. Is Respondent knowledgeable about the application, status review, recertification, and appeals process for social security benefits? |
|Yes No |
|5. Is Respondent knowledgeable about Medicaid and Managed Care Organizations? |
|Yes No |
1
12 Form F: Organizational Overview, Philosophy, or Mission Statement
Respondent shall use this space to submit proof of organizational overview, philosophy, or mission statement, if applicable. (Respondent may add additional pages, maximum of 5 pages total, 12 pt. font, and double spaced).
13 Form G: Organizational Chart/Structure
Respondent shall use this space to submit proof of organizational/chart structure.
Respond must use a 12 point font with double spaced lines. Additional pages may be added as needed.
14 Form H: Policies and Procedures
Respondent shall provide URL or attach organizational policies and procedures for providing HCBS-AMH services. Respondent must use a 12 point font with double spaced lines. For additional information, refer to the Provider Manual located at:
15 Form I: Job Description for the HCBS-AMH Recovery Management Position
Respondent shall attach job description for the HCBS-AMH Recovery Management Position. Respondent must use a 12 point font with double spaced lines. Additional pages may be added as needed.
16
17 FORM J: Proof of General Liability Insurance
Respondent shall attach proof of general liability insurance.
18
19 FORM K: Organization Brochure or Biographical Information
20
Respondent shall use this space to submit an organizational brochure or biographical information. Additional pages may be added as needed.
1 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 RFP if the bid includes financial participation with the Respondent by a person who received compensation from DSHS to participate in preparing the specification of RFP on which the bid is based;
3. Has a financial system that identifies the source and application of DSHS funds and program income in a unique set of general ledger account numbers, permits preparation of reports required by the contract, permits the tracing of funds expended and program income, allows for the comparison of actual expenditures to budgeted amounts, and maintains accounting records that are supported by verifiable source documents;
4. Will give (and any parent, affiliate, or subsidiary organization, if such a relationship exists, will give) DSHS, HHSC Office of Inspector General, the Texas State Auditor, the Comptroller General of the United States, and if appropriate, the federal government, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives;
5. Will not supplant funds (i.e. use funds from a contract awarded as a result of this RFP to replace or substitute existing funding from other sources that also supports the activities that are the subject of the contract), but rather will use funds from the contract to supplement any existing funds currently available for any such activities;
6. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain;
7. Will ensure that no officer, employee, or member of the Respondent’s governing body or of the Respondent’s contractor will vote or confirm the employment of any person related within the second degree of affinity or the third degree of consanguinity (as defined in Texas Government Code Chapter 573) to any member of the governing body or to any other officer or employee authorized to employ or supervise such person. This prohibition does not prohibit the continued employment of a person who has been continuously employed for a period of two years, or such other period stipulated by local law, prior to the election or appointment of the officer, employee, or governing body member related to such person in the prohibited degree;
8. Has not given, offered to give, nor intends to give, at any time hereafter any economic opportunity, present or future employment, gift, loan, gratuity, special discount, trip, favor, or service to any employee or official of DSHS or HHSC, in connection with this solicitation or procurement; does not have nor will it knowingly acquire any interest that would conflict in any manner with the performance of its obligations under any awarded contract that results from this RFP;
9. Will honor for 90 days after the proposal due date the technical and business terms contained in the proposal;
10. Will initiate the work after receipt of a fully executed contract and will complete it within the contract period;
11. Will not require a client with limited English proficiency to provide or pay for the services of a translator or interpreter;
12. Will identify and document on client records the primary language/dialect of a client who has limited English proficiency and the need for translation or interpretation services;
13. Will make every effort to avoid use of any persons under the age of 18 or any family member or friend of a client as an interpreter for essential communications with clients who have limited English proficiency. However, a family member or friend may be used as an interpreter if this is requested by the client and the use of such a person would not compromise the effectiveness of services or violates the client’s confidentiality, and the client is advised that a free interpreter is available;
14. Will comply with the Uniform Grant Management Act (UGMA), Texas Government Code, Chapter 783, as amended, and the current Uniform Grant Management Standards (UGMS), issued by the Governor's Budget and Planning Office, applicable Office of Management and Budget Federal Circulars, and if applicable the Federal awarding agency Common Rule and U.S. Department of Health and Human Services Grants Policy Statements, which apply as terms and conditions of any resulting contract. A copy of the UGMS manual and federal references available upon request;
15. Will remain current in its payment of franchise tax or is exempt from payment of franchise taxes, if applicable;
16. Will comply, if applicable, with Texas Family Code, § 231.006, regarding Child Support, and certifies that it is not ineligible to receive payment if awarded a contract, and acknowledges that any resulting contract may be terminated, and payment may be withheld if this certification is inaccurate;
17. Will comply with the non-discriminatory requirements of Texas Labor Code, Chapter 21, which requires that certain employers not discriminate on the basis of race, color, disability, religion, sex, national origin, or age;
18. Will not charge a fee or profit. A profit and/or fee are considered to be an amount in excess of actual allowable costs that are incurred in conducting an assistance program;
19. Will comply with all applicable requirements of all other state/federal laws, executive orders, regulations, and policies governing this program;
20. In accordance with 2 CFR Part 376 and 180 (parts A-I), as the primary participant, and any of the primary participant’s principals (collectively, participants):
A. are not presently disqualified, debarred, suspended, proposed for debarment, declared ineligible, or excluded from covered transactions by any federal department or agency;
B. have not within a 3-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a private or public (federal, state, or local) transaction or contract under a private or public transaction; violation of federal or state antitrust statutes (including those proscribing price fixing between competitors, allocation of customers between competitors and bid rigging) or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements or false claims, tax evasion, obstruction of justice, receiving stolen property or any other offense indicating a lack of business integrity or business honesty that seriously and directly affects the participant’s present responsibility;
C. are not presently indicted or otherwise criminally or civilly charged by a governmental Respondent (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) of this certification;
D. have not within a 3-year period preceding this proposal/proposal had one or more public transactions (federal, state, or local) terminated for cause or default; and
E. has not (nor has its representative nor any person acting for the representative) (1) violated the antitrust laws codified by Chapter 15, Texas Business & Commercial Code, or the federal antitrust laws; or (2) directly or indirectly communicated the bid to a competitor or other person engaged in the same line of business.
Should the Respondent not be able to provide this certification (by signing the FACE PAGE Form), an explanation should be placed after this form in the proposal response;
The Respondent agrees by submitting this proposal that the Respondent will include, without modification, the certifications in subparagraphs A through E of this paragraph in all lower tier covered transactions (i.e., transactions with sub grantees and/or contractors) and in all solicitations for lower tier covered transactions;
21. Will comply with Title 31, USC §1352, entitled “Limitation on use of appropriated funds to influence certain federal contracting and financial transactions,” which generally prohibits recipients of federal grants and cooperative agreements from using federal (appropriated) funds for lobbying the executive or legislative branches of the federal government in connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires that each person who requests or receives a federal grant or cooperative agreement must disclose lobbying undertaken with non-federal (non-appropriated) funds. These requirements apply to grants and cooperative agreements EXCEEDING $100,000 in total costs (45 CFR Part 93):
A. No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement;
B. If any funds other than federally-appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agent, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the Respondent must complete and submit Standard Form-LLL, “Disclosure of Lobbying Activities,” (SF-LLL) in accordance with its instructions. SF-LLL and continuation sheet are available upon request from the Department of State Health Services; and
C. The language of this certification must be included in the award documents for all sub-awards at all tiers (including subcontracts, sub grants, and contracts under grants, loans and cooperative agreements) and that all sub recipients must certify and disclose accordingly;
This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31 USC §1352. Any person who fails to file the required certification must be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure;
22. Is in good standing with the Internal Revenue Service on any debt owed;
23. Affirms that no person who has an ownership or controlling interest in the organization or who is an agent or managing employee of the organization has been placed on community supervision, received deferred adjudication or been convicted of a criminal offense related to any financial matter, federal or state program or felony sex crime;
24. Is in good standing with all state and/or federal departments or agencies that have a contracting relationship with the Respondent;
25. Will comply with all statutes and standards of general applicability. It is Respondent’s responsibility to review and comply with all applicable statutes, rules, regulations, executive orders and policies. Respondent will carry out the terms of this Contract in a manner that is in compliance with the provisions set forth below. To the extent such provisions are applicable to Respondent; Respondent will comply with the following:
a) The following statutes, rules, regulations and DSHS policies, and any of their subsequent amendments that collectively prohibit discrimination on the basis of race, color, national origin, limited English proficiency, sex, sexual orientation (where applicable), disabilities, age, substance abuse, political belief, or religion: 1) Title VI of the Civil Rights Act of 1964, 42 U.S.C.A. §§∍ 2000d et seq.; 2) Title IX of the Education Amendments of 1972, 20 U.S.C.A. §∍∍§ 1681-1683, and 1685-1686; 3) Section 504 of the Rehabilitation Act of 1973, 29 U.S.C.A. § 794(a); 4) the Americans with Disabilities Act of 1990, 42 U.S.C.A. §§∍ 12101 et seq.; 5) Age Discrimination Act of 1975, 42 U.S.C.A. §∍∍§ 6101-6107: 6) Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970, 42 U.S.C.A. §∍ 290dd (b)(1); 7) 45 CFR Parts 80, 84, 86 and 91 or CFR Part 15; 8) Tex. Lab. Code, ch. 21; 9) Food Stamp Act of 1977 (7 USC §200 et seq); 10) US Department of Labor, Equal Opportunity E.O. 11246, as amended and supplemented; 11) Executive Order 13279 and 45 CFR Part 87 or 7 CFR Part 16 (regarding equal treatment and opportunity for religious organizations; 12) DSHS Policy AA-5018, Non-discrimination Policies and Procedures for DSHS Programs; and13) any other nondiscrimination provision in specific statutes under which application for federal or state assistance is being made, which prohibits exclusion from or limitation of participation in programs, benefits, or activities, or denial of any aid, care, service or other benefit;
b) Drug Abuse Office and Treatment Act of 1972, 21 U.S.C.A. §§ 1101 et seq., relating to drug abuse;
c) Public Health Service Act of 1912, §§∍ 523 and 527, 42 U.S.C.A. §∍ 290dd-2, and 42 C.F.R. pt. 2, relating to confidentiality of alcohol and drug abuse patient records;
d) Title VIII of the Civil Rights Act of 1968, 42 U.S.C.A. §§ 3601 et seq., relating to nondiscrimination in housing;
e) Immigration Reform and Control Act of 1986, 8 U.S.C.A. § 1324a, regarding employment verification;
f) Pro-Children Act of 1994, 20 U.S.C.A. §§ 6081-6084, regarding the non-use of all tobacco products;
g) National Research Service Award Act of 1971, 42 U.S.C.A. §§∍ 289a-1 et seq., and 6601 (P.L. 93-348 and P.L. 103-43), as amended, regarding human subjects involved in research;
h) Hatch Political Activity Act, 5 U.S.C.A. §§∍∍ 7321-26, which limits the political activity of employees whose employment is funded with federal funds;
i) Fair Labor Standards Act, 29 U.S.C.A. §§ 201 et seq., and the Intergovernmental Personnel Act of 1970, 42 U.S.C.A. §§ 4701 et seq., as applicable, concerning minimum wage and maximum hours;
j) Tex. Gov’t Code ch. 469 (Supp. 2004), pertaining to eliminating architectural barriers for persons with disabilities;
k) Texas Workers’ Compensation Act, Tex. Labor Code, chs. 401-406 28 Tex. Admin. Code pt. 2, regarding compensation for employees’ injuries;
l) The Clinical Laboratory Improvement Amendments of 1988, 42 USC § 263a, regarding the regulation and certification of clinical laboratories;
m) The Occupational Safety and Health Administration Regulations on Blood Borne Pathogens, 29 CFR § 1910.1030, or Title 25 Tex. Admin Code ch. 96 regarding safety standards for handling blood borne pathogens;
n) Laboratory Animal Welfare Act of 1966, 7 USC §§ 2131 et seq., pertaining to the treatment of laboratory animals;
o) Environmental standards pursuant to the following: 1) Institution of environmental quality control measures under the National Environmental Policy Act of 1969, 42 USC §§ 4321-4347 and Executive Order 11514 (35 Fed. Reg. 4247), “Protection and Enhancement of Environmental Quality;” 2) Notification of violating facilities pursuant to Executive Order 11738 (40 CFR Part 32), “Providing for Administration of the Clean Air Act and the Federal Water Pollution Control Act with respect to Federal Contracts, Grants, or Loans;” 3) Protection of wetlands pursuant to Executive Order 11990, 42 Fed. Reg. 26961; 4) Evaluation of flood hazards in floodplains in accordance with Executive Order 11988, 42 Fed. Reg. 26951 and, if applicable, flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234); 5) Assurance of project consistency with the approved State Management program developed under the Coastal Zone Management Act of 1972, 16 USC §§ 1451 et seq; 6) Conformity of federal actions to state clean air implementation plans under the Clean Air Act of 1955, as amended, 42 USC §§ 7401 et seq.; 7) Protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, 42 USC §§ 300f-300j; 8) Protection of endangered species under the Endangered Species Act of 1973, 16 USC §§ 1531 et seq.; 9) Federal Water Pollution Control Act, 33 USC §1251 et seq.; 10) Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§ 1271 et seq.) related to protecting certain rivers system; and 11) Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§ 4801 et seq.) prohibiting the use of lead-based paint in residential construction or rehabilitation;
p) Intergovernmental Personnel Act of 1970 (42 USC §§4278-4763 regarding personnel merit systems for programs specified in Appendix A of the federal Office of Program Management’s Standards for a Merit System of Personnel Administration (5 C.F.R. Part 900, Subpart F);
q) Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646), relating to fair treatment of persons displaced or whose property is acquired as a result of Federal or federally-assisted programs;
r) Davis-Bacon Act (40 U.S.C. §§ 276a to 276a-7), the Copeland Act (40 U.S.C. § 276c and 18 U.S.C. § 874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. §§ 327-333), regarding labor standards for federally-assisted construction sub-agreements;
s) Assist DSHS in complying the National Historic Preservation Act of 1966, §106 (16 U.S.C. § 470), Executive Order 11593, and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§ 469a-1 et seq.) regarding historic property;
t) Financial and compliance audits in accordance with Single Audit Act Amendments of 1996 and OMB Circular No. A-133, “Audits of States, Local Governments, and Non-Profit Organizations;” and
u) Requirements of any other applicable state and federal statutes, executive orders, regulations, rules, and policies.
If this contract is funded by a grant, additional state or federal requirements found in the Notice of Grant Award may be imposed on Respondent;
26. Under §§2155.006 and 2261.053, Government Code, is not ineligible to receive a contract under this RFP and acknowledges that any contract may be terminated, and payment withheld if this certification is inaccurate. Sections 2155.006 and 2261.053 relate to violations of federal law in connection with a contract awarded by the federal government for relief, recovery or reconstruction efforts as a result of Hurricanes Rita or Katrina or certain other disasters;
27. Affirms that the statements in these assurances and certifications are true, accurate, and complete (to the best of Respondent’s and its authorized representative’s knowledge and belief) and agrees to comply with the DSHS terms and conditions if an award is issued as a result of this proposal. Willful provision of false information is a criminal offense. Any person making any false, fictitious, or fraudulent statement may, in addition to other remedies available, be subject to civil penalties.
APPENDIX B: GENERAL PROVISIONS
The FY 2015 Core Vendor General Provisions can be found at the following link. .
APPENDIX C: STANDARDIZED RATES OR APPROVED COSTS
The HCBS-AMH Program is a fee for service program. Rates are available through SYSTEM AGENCY’s website at
APPENDIX D: LMHA SERVICE REGIONS BY COUNTY
|Region 1: |Anderson, Cherokee |
|Region 2: |Henderson, Smith, Van Zandt, Rains, Wood |
|Region 3: |Travis |
|Region 4: |Jones, Taylor, Shackel-Ford, Callahan, Stephens |
|Region 5: |Burnet, Williamson, Lee, Bastrop, Fayette, Caldwell, Guadalupe, Gonzales |
|Region 6: |Webb, Zapata, Jim Hogg, Starr |
|Region 7: |Robertson, Leon, Madison, Brazos, Grimes, Burleson, Washington |
|Region 8: |Houston, Nacogdoches, Shelby, San Augustine, Angelina, Sabine, Trinity, Polk, San Jacinto, Tyler, Jasper, Newton |
|Region 9: |Maverick, Zavala, Dimmit, Frio, La Salle, Atascosa, McMullen, Wilson, Karnes |
|Region 10: |Bexar |
|Region 11: |Coleman, Brown, Eastland, Comanche, Mills, McCulloch, San Saba |
|Region 12: |Hamilton, Coryell, Lampasas, Bell, Milam |
|Region 13: |Parmer, Castro, Swisher, Briscoe, Bailey, Lamb, Hale, Floyd, Motley |
|Region 14: |Bee, Live Oak, San Patricio, Duval, Jim Wells, Kleberg, Brooks, Kenedy, Aransas |
|Region 15: |Sterling, Coke, Reagan, Irion, Tome Green, Concho, Crockett |
|Region 16: |Dallas, Ellis, Navarro, Kaufman, Rockwall, Hunt |
|Region 17: |Denton |
|Region 18: |El Paso |
|Region 19: |Lavaca, Dewitt, Jackson, Victoria, Goliad, Calhoun, Refugio |
|Region 20: |Galveston, Brazoria |
|Region 21: |Harris |
|Region 22: |Bosque, Hill, McLennan, Limestone, Freestone, Falls |
|Region 23: |Childress, Cottle, Dickens, King, Stonewall, Hardeman, Foard, Knox, Haskell, Wilbarger, Baylor, Throck-Morton, Wichita,|
| |Archer, Young, Clay, Jack, Montague, Wise |
|Region 24: |Val Verde, Schleicher, Sutton, Edwards, Kinney, Menard, Kimble, Real, Uvalde, Mason, Gillespie, Kerr, Bandera, Medina, |
| |Llano, Blanco, Kendall, Hays, Comal |
|Region 25: |Hopkins, Lamar, Delta, Franklin, Titus, Camp, Morris |
|Region 26: |Collin |
|Region 27: |Cochran, Hockley, Lubbock, Lynn, Crosby |
|Region 28: |Nueces |
|Region 29: |Palo Pinto, Parker, Erath, Hood, Johnson, Somervell |
|Region 30: |Hudspeth, Culberson, Jeff Davis, Pecos, Presidio, Brewster, Ector, Midland |
|Region 31: |Red River, Bowie, Cass, Marion, Upshur, Gregg, Harrison, Rusk, Panola |
|Region 32: |Hardin, Orange, Jefferson, Chambers |
|Region 33: |Tarrant |
|Region 34: |Austin, Waller, Colorado, Fort Bend, Wharton, Matagorda |
|Region 35: |Dallam, Sherman, Hansford, Ochiltree, Lipscomb, Hartley, Moore, Hutchinson, Roberts, Hemphill, Oldham, Potter, Carson, |
| |Gray, Wheeler, Deaf Smith, Randall, Armstrong, Donley, Collingsworth, Hall |
|Region 36: |Cooke, Grayson, Fannin |
|Region 37: |Walker, Montgomery, Liberty |
|Region 38: |Hidalgo, Willacy, Cameron |
|Region 39: |Runnels, Terrell, Upton, Crane, Ward, Loving, Winkler, Glasscock, Andrews, Martin, Howard, Mitchell, Nolan, Gaines, |
| |Dawson, Borden, Scurry, Fischer, Yoakum, Terry, Garza, Kent, Reeves |
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