DHS-7004B-ENG (HCBS Waiver/AC Approval-Option Service ...
Minnesota HCBS Waiver/AC
Approval-Option Service Vendor
Assurance Statement Template
(County/tribal agencies/MCO that approve direct-delivery service vendors must complete this vendor assurance statement.)
This agreement is effective beginning on ____ (enter date) ____.
Service vendor ___ (enter vendor name )______ agrees to the following in delivering services to Minnesota Home and Community-Based Services Waiver (BI, CAC, CADI, DD, EW)/Alternative Care (AC) participants through __ (enter county/tribal agency/MCO) __.
• On an ongoing basis, ensure that all vendor owners, managers, employees, and contractors are not excluded from participation in Medicare, Medicaid, or other federal health programs, per the Office of Inspector General List of Excluded Individuals/Entities (LEIE) and do not appear on the MHCP Excluded Provider Lists. Vendor agrees to immediately report any exclusion information discovered to___(enter county/tribal agency/MCO) __.
• Notify ____ (enter county/tribal agency/MCO) _______ case manager/care coordinator and suspend service delivery in the event of expiration or revocation of a required licensure, certification, registration or insurance or change in required background study status.
• Ensure proper handling and safeguarding of protected information collected, created, used or disclosed on behalf of ___ (enter county/tribal agency/MCO) ___ and DHS and in accordance with the federal Health Insurance Portability and Accountability Act, including but not limited to the requirements of the:
o Privacy rule and the security regulations, 45 CFR 160 and 164
o The Minnesota Government Data Practices Act, Minnesota Statute Chapter 13, in particular 13.46 Welfare Data
o The Minnesota Medical Records Act, Minnesota Statutes 144.291 – 144.298
o Any other applicable state and federal statutes, rules and regulations affecting the collection, storage, use and dissemination of private or confidential information.
• Comply with all federal statutes and guidance prohibiting discrimination on the basis of race, color, national origin, sex, age, religion or disability.
• Deliver to waiver participants service of the same scope and quality as would be provided to the general public and in compliance with HCBS waiver/AC program guidelines. Accept Medical Assistance payment as payment in full for HCBS/AC waiver services.
• Deliver services as specified by the waiver participant’s support plan and at the service rate established by the county/tribal agency or MCO.
• Agree to maintain, for five years, financial records that contain evidence of vendor charges for HCBS waiver/AC services as authorized by the case manager/care coordinator and that document each occurrence of service provided. Agree to make records available for review upon request.
• Report all child abuse for clients under age 18 to the county/tribal agency and vulnerable adult maltreatment for clients 18 years and older to Minnesota Adult Abuse Reporting Center (1-844-880-1574.)
Table 1: Service-specific requirements and vendor assurances
|Service |Check as applicable that lead agency has verified or vendor assures |
|Chore services – pesticide applicator | Structural pesticide applicators: The lead agency verifies active structural pesticide applicator |
| |licensure and maintains a file copy of license presented at vendor approval. (See the Minnesota Department |
| |of Agriculture license look-up to verify licensure) |
|Environmental accessibility adaptations/ | Home modification installations (licensure requirements: Minn. Stat., Chapter 326B): The lead agency |
|home modification/ installation |verifies active licensure/certification as required for this service and maintains a file copy of the |
| |license presented at vendor approval. (See the Minnesota Department of Labor & Industry license look-up.) |
| |NOTE: Minn. Stat. § 326B.805 subd. 6 lists residential building contractor licensing requirement |
| |exemptions. |
| |Building contractor assures that all vendors will execute installations in accordance with applicable state |
| |and local building codes. |
|Environmental accessibility adaptations/ | Vehicle modification installations: The lead agency verifies the vendor is registered as a “vehicle |
|vehicle modification/ installation |modifier” with the National Highway Traffic Safety Administration. |
|Homemaker/cleaning | The lead agency verifies completion of a DHS background study for the vendor (may be an individual or |
| |agency owner/manager) and maintains a file copy of the study results. |
| |An agency vendor assures s/he will initiate a DHS background study for each employee who delivers services |
| |to HCBS waiver/AC participants and comply with all requirements in Minn. Stat., Chapter 245C. |
|Family training and counseling / training| The lead agency verifies completion of a DHS background study for the vendor (may be an individual or |
| |agency owner/manager) and maintains a file copy of the study results. |
|(BI, CAC, CADI, DD) |An agency vendor initiates a DHS background study for each employee who delivers services to HCBS waiver/AC |
|one-on-one, in-home |participants and comply with all requirements in Minn. Stat., Chapter245C. |
| |As required by the type of training: The lead agency verifies active licensure/certification for this |
| |service and maintains a copy of the license on file. |
|Service | Check as applicable that lead agency has verified or vendor assures |
|Family caregiver training and education | The lead agency verifies completion of a DHS background study for the vendor (may be an individual or |
|(AC, EW) |agency owner/manager) and maintains a file copy of the study results. |
|one-on-one |An agency vendor will initiate a DHS background study for each employee who delivers services to HCBS |
| |waiver/AC participants and comply with all requirements in Minn. Stat., Chapter245C. |
| |As required by the type of training and education: The lead agency verifies active licensure/certification |
| |for this service and maintains a copy of the license on file. |
|Transitional services/ | The lead agency verifies completion of a DHS background study for the vendor (may be an individual or |
|EW-related supports |agency owner/manager) and maintains a file copy of the study results. |
|(does not apply to strictly item |An agency vendor will initiate a DHS background study for each employee who delivers services to HCBS |
|purchases) |waiver/AC participants and comply with all requirements in Minn. Stat., Chapter245C. |
|Transportation/ | The lead agency verifies active individual driver licensure and automobile insurance as required by Minn.|
|non-commercial, individual driver |Stat. Ch. 65B and maintains file copies of the documentation presented at the time of vendor approval. |
| |(Volunteer agencies may furnish, for their volunteer drivers, documentation attesting to the active |
| |licensure and automobile insurance required by Minn. Stat. Chapter 65B.) |
|AC discretionary services | The lead agency verifies completion of a DHS background study for the vendor (may be an individual or |
|one-on-one |agency owner/manager) and maintains a file copy of the study results. |
| |An agency vendor will initiate a DHS background study for each employee who delivers services to HCBS |
| |waiver/AC participants and comply with all requirements in Minn. Stat., Chapter 245C. |
| |As required by the type of AC Discretionary service: The lead agency verifies active |
| |licensure/certification for this service and maintains a copy of the license on file. |
This vendor assurance statement attaches to all waiver service purchase agreements/arrangements entered into within five calendar years of the date of vendor signature on this assurance document.
This vendor assurance shall become null and void on ____ (enter date) ____, or when the vendor’s license, certification or registration to provide these services expires, is suspended or revoked. The vendor is an independent service contractor and nothing herein contained shall be construed to create the relationship of employer and employee between ____ (enter county/tribal agency/MCO) _______ and the vendor.
________________________________ ________ ________________________________ ________
Service vendor signature Date County/tribal agency/MCO signature Date
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.