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Home My WebLink About20091280.tiffRESOLUTION RE: APPROVE TASK ORDER CONTRACT FOR WOMEN'S WELLNESS CONNECTION PROGRAM AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with a Task Order Contract for the Women's Wellness Connection Program between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Department of Public Health and Environment, commencing June 30, 2009, and ending June 29, 2012, with further terms and conditions being as stated in said contract, and WHEREAS, after review, the Board deems it advisable to approve said contract, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Task Order Contract for the Women's Wellness Connection Program between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Department of Public Health and Environment be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said contract. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 3rd day of June, A.D., 2009. - ATTEST: Weld County Clerk to the B BY Deputy t' to the Board APPROVED AS TO FORM: n ACou j Atto ey Date of signature 6K/7/(77 BOARD OF COUNTY COMMISSIONERS ELMNT�tLORADO am F. Garcia, Chair viAa ugla- 'adema'her, Pro-Tem Sean P. Conway EXCUSED Barbera Kirkmeyer David E. Long `Fl 1 //L (;71c-, 2009-1280 HL0036 C 1///cr 0*:Tirg WilDe COLORADO Memorandum TO: William F. Garcia, Chair Board of County Commissioners FROM: Mark E. Wallace, MD, MPH, Director Department of Public Health and ,, �j� Environment 1. _ i2 p oh DATE: May 26, 2009 �V�i�•�!� SUBJECT: Women's Wellness Connection Service Delivery Contract Enclosed for Board review and approval is a contract between the Colorado Department of Public Health and Environment Women's Wellness Connection Program (WWC) and the Weld County Board of Commissioners on behalf of the Department of Public Health and Environment. Funding for these services is provided by both federal and state sources. Weld County Department of Public Health and Environment will provide breast and cervical cancer screening services, case management, diagnostic services, data coordination, referral of women to the program's Treatment Navigator and administrative services (eligibility determination, enrollment, and translation). For providing these services during the time period June 30, 2009 through June 29, 2012, the State will reimburse Weld County at a global rate according to the levels of care provided to the women and described on the attached Global Level Reimbursement Fee Structure. I recommend your approval of this contract. Enclosure 2009-1280 STATE OF COLORADO Bill Ritter, Jr., Governor James B. Marlin, Executive Director Dedicated to protecting and improving the health and environment of the people of Colorado 4300 Cherry Creek Dr. S. Denver, Colorado 80246-1530 Phone (303) 692-2000 TDD Line (303) 691-7700 Located in Glendale, Colorado http://www.cdphe.state.co.us Laboratory Services Division 8100 Lowry Blvd. Denver, Colorado 80230-6928 (303) 692-3090 WORK STATUS CONFIRMATION LETTER Vendor Name: Weld County Department of Public Health and Environment Colorado Department of Public Health and Environment Contract Routing Number: 9 FLA 01030 CRS §24-30-202 requires the State Controller to approve all State Contracts. The above referenced Amendment is not valid until it is signed and dated below by the State Controller or delegate. Therefore, your agency is not authorized to begin performance until you are notified that it's signed. If your agency begins performing Contract tasks prior to that date, the State of Colorado is not obligated to pay your agency for such performance or for any goods and/or services provided prior to the date signed. By signing below, your confirm that (Signature MUST be that of the person signing the Contract) a) No work has been performed under this contract b) No work will begin under this contract until the contract is signed by the State Controller or on the effective date, whichever is later. 2 Signature of Authorized Officer William F. Garcia Print Name of Authorized Officer Chair, Weld County Board of Commissioners Print Title of Authorized Officer 06/03/2009 Date Signed RETURN THIS FORM WITH YOUR CONTRACT Page 1 of 1 .'R009 --144o DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT ROUTING NO. 9 FLA 01030 APPROVED TASK ORDER CONTRACT - WAIVER #154 This Task Order Contract is issued pursuant to Master Contract made on 01/23/07, with routing number 08 FAA 00052 STATE: State of Colorado for the use & benefit of the Department of Public Health and Environment PSD-WWC 4300 Cherry Creek Drive South Denver, Colorado 80246 TASK ORDER MADE DATE: 04/24/09 PO/SC ENCUMBRANCE NUMBER: PO FLA WHSI0WWC TERM. This Task Order shall be effective upon approval by the State Controller, or designee, or on 06/30/09, whichever is later. The Task Order shall end on 06/29/2012. PRICE STRUCTURE: Cost Reimbursement PROCUREMENT METHOD: Exempt BID/REP/LIST PRICE AGREEMENT NUMBER Not Applicable LAW SPECIFIED VENDOR STATUTE: Not Applicable STATE REPRESENTATIVE: Sandra Mortensen Department of Public Health and Environment PSD-WWC 4300 Cherry Creek Drive South Denver, CO 80246 SCOPE OF WORK CONTRACTOR: Board of County Commissioners of Weld County 915 10th Street Greeley, Colorado 80632-0758 for the use and benefit of the Weld County Department of Public Health and Environment, 1555 North 17th Avenue Greeley, Colorado 80631 CONTRACTOR ENTITY TYPE: Colorado Political Subdivision BE LING STATEMENTS RECEIVED: Monthly STATUTORY AUTHORITY: Not Applicable CONTRACT PRICE NOT TO EXCEED- S CONTRACTOR TO RECEIVE A PORTION OF THE BLANKET ENCUMBRANCE AMOUNT FEDERAL FUNDING DOLLARS: STATE FUNDING DOLLARS: $ Contractor to receive a portion of the blanket encumbrance amount $ Contractor to receive a portion of the blanket encumbrance amount MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR: CONTRACTOR REPRESENTATIVE Judy Nero 1555 north 17th Ave Greeley CO 80631 To deliver Women Wellness Connection services within the Contractor's existing network of subcontractors. Page 1 of 6 Rev 4/3/09 EXHIBITS: The following exhibits are hereby incorporated: Exhibit A - Additional Provisions (and its attachments if any — e.g., A-1, A-2, etc.) Exhibit B - Statement of Work and Budget (and its attachments if any — e.g., B-1, B-2, etc.) Exhibit C - Limited Amendment Template for Task Orders Exhibit D- Option Letter GENERAL PROVISIONS The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task Order Contract provide more specificity than these general clauses, the more specific provision shall control. I. This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract including, but not limited to, Exhibit One thereto. The total term of this Task Order Contract, including any renewals or extensions, may not exceed five (5) years. The parties intend and agree that all work shall be performed according to the standards, terms and conditions set forth in the Master Contract. 2. In accordance with section 24-30-202(1), C.R.S., as amended, this Task Order Contract is not valid until it has been approved by the State Controller, or an authorized delegee thereof. The Contractor is not authorized to, and shall not; commence performance under this Task Order Contract until this Task Order Contract has been approved by the State Controller or delegee. The State shall have no financial obligation to the Contractor whatsoever for any work or services or, any costs or expenses, incurred by the Contractor prior to the effective date of this Task Order Contract. If the State Controller approves this Task Order Contract on or before its proposed effective date, then the Contractor shall commence performance under this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order Contract after its proposed effective date, then the Contractor shall only commence performance under this Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through and including the date specified on page one of this Task Order Contract, unless sooner terminated by the parties pursuant to the terms and conditions of this Task Order Contract and/or the Master Contract. Contractor's commencement of performance under this Task Order Contract shall be deemed acceptance of the terms and conditions of this Task Order Contract. 3. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made a part hereof as if fully set forth herein. Unless otherwise stated, all exhibits and/or attachments to this Task Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated, the terms of this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event of conflicts or inconsistencies between the Master Contract and this Task Order Contract (including its exhibits and/or attachments), or between this Task Order Contract and its exhibits and/or attachments, such conflicts or inconsistencies shall be resolved by reference to the documents in the following order of priority: 1) the Page 2 of 5 Rev 4/3/09 Special Provisions of the Master Contract; 2) the Master Contract (other than the Special Provisions) and its exhibits and attachments in the order specified in the Master Contract; 3) this Task Order Contract; 4) the Additional Provisions -_Exhibit A, and its attachments if included, to this Task Order Contract; 5) the Scope/Statement of Work - Exhibit B, and its attachments if included, to this Task Order Contract; 6) other exhibits/attachments to this Task Order Contract in their order of appearance. 4. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order Contract, shall perform and complete, in a timely and satisfactory manner, all work items described in the Statement of Work and Budget, which are incorporated herein by this reference, made a part hereof and attached hereto as "Exhibit B". 5. The State, with the concurrence of the Contractor, may, among other things, prospectively renew or extend the term of this Task Order Contract, subject to the limitations set forth in the Master Contract, increase or decrease the amount payable under this Task Order Contract, or add to, delete from, and/or modify this Task Order Contract's Statement of Work through a "Limited Amendment for Task Orders" that is substantially similar to the sample form Limited Amendment that is incorporated herein by this reference and identified as Exhibit C. To be effective, this Limited Amendment must be signed by the State and the Contractor, and be approved by the State Controller or an authorized delegate thereof. Upon proper execution and approval, this Limited Amendment shall become a formal amendment to this Task Order Contract. This contract is subject to such modifications as may be required by changes in Federal or State law, or their implementing regulations. Any such required modification shall automatically be incorporated into and be part of this Task Order Contract on the effective date of such change as if fully set forth herein. 6. The conditions, provisions, and terms of any RFP attached hereto, if applicable, establish the minimum standards of performance that the Contractor must meet under this Task Order Contract. If the Contractor's Proposal, if attached hereto, or any attachments or exhibits thereto, or the Scope/Statement of Work - Exhibit B, establishes or creates standards of performance greater than those set forth in the RFP, then the Contractor shall also meet those standards of performance under this Task Order Contract. 7. STATEWIDE CONTRACT MANAGEMENT SYSTEM [This section shall apply when the Effective Date is on or after July 1, 2009 and the maximum amount payable to Contractor hereunder is $100,000 or higher] By entering into this Task Order Contract, Contractor agrees to be governed, and to abide, by the provisions of CRS §24-102-205, §24-102-206, §24-103-601, §24-103.5-101 and §24-105-102 concerning the monitoring of vendor performance on state contracts and inclusion of contract performance information in a statewide contract management system. Contractor's performance shall be evaluated in accordance with the terms and conditions of this Task Order Contract, State law, including CRS §24-103.5-101, and State Fiscal Rules, Policies and Guidance. Evaluation of Contractor's performance shall be part of the normal contract administration process and Contractor's performance will be systematically recorded in the statewide Contract Management System. Areas of review shall include, but shall not be limited to quality, cost and timeliness. Collection of information relevant to the performance of Contractor's obligations under this Task Order Contract shall be determined by the specific requirements of such obligations and shall include factors tailored to match the requirements of the Statement of Project of this Task Order Contract. Such performance information shall be entered into the statewide Contract Management System at intervals established in the Statement of Project and a final review and rating shall be rendered within 30 days of the end of the Task Order Contract term. Contractor shall be notified following each performance and shall address or correct any identified problem in a timely manner and maintain work progress. Should the fmal performance evaluation determine that Contractor demonstrated a gross failure to meet the performance measures established under the Statement of Project, the Executive Director of the Colorado Department of Personnel and Administration (Executive Director), upon request by the Colorado Department of Public Health and Environment and showing of good cause, may debar Contractor and Page 4 of 6 Rev 4/3/09 prohibit Contractor from bidding on future contracts. Contractor may contest the final evaluation and result by: (i) filing rebuttal statements, which may result in either removal or correction of the evaluation (CRS §24-105-102(6)), or (ii) under CRS §24-105-102(6), exercising the debarment protest and appeal rights provided in CRS §§24-109-106, 107, 201 or 202, which may result in the reversal of the debarment and reinstatement of Contractor, by the Executive Director, upon showing of good cause. Page 5 of 6 Rev 4/3/09 THE PARTIES HERETO HAVE EXECUTED THIS CONTRACT * Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's behalf and acknowledge that the State is relying on their representations to that effect. CONTRACTOR: Board of County Commissioners of Weld County for the use and benefit of the Weld County Department of Public Health and Environment Legal Name of Contracting Entity Signature of Authorized Officer U N —' 3 2009 William F. Garcia Print Name of Authorized Officer Chair Print Title of Authorized Officer STATE OF COLORADO: BILL RITTER, JR. GOVERNOR By For Executive Director Department of Public Health and Environment Signatory avers to the State Controller or delegate that Contractor has not begun performance or that a Statutory Violation waiver has been requested under Fiscal Rules Departrn t Program Approval: By ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until signed and dated below by the State Controller or delegate. Contractor is not authorized to begin performance until such time. If Contractor begins performing prior thereto, the State of Colorado is not obligated to pay Contractor for such performance or for any goods and/or services provided hereunder. By Date STATE CONTROLLER: David J. McDermott, CPA WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIH.ON ENT BY: I k'W\��JlEl Page 5 of 5 Mark E. Wallace, MD. MPH - Director Rev 4/3/09 ,oi-/271'C) EXHIBIT A ADDITIONAL PROVISIONS To Task Order Contract Dated 04/24/09 - Contract Routing Number 09 FLA 01030 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Determination. The State has determined that this contract does not constitute a Business Associate relationship under HIPAA. 2. This Task Order Contract contains federal funds (see Catalog of Federal Domestic Assistance (CFDA) number 93.283 and State Cash Funds. 3. The United State Department of Health and Human Services ("USDHHS"), through the Centers for Disease Control and Prevention ("CDC") has awarded federal funds under Award number U58 DP000848- 03, hereinafter "Award", to perform breast cancer screenings and cervical cancer screenings, and diagnostic services if needed to the point of a definitive diagnosis. The intent of the Cooperative Agreement is to increase screening diagnosis among low income older women who are uninsured or under insured, including those who are racial, ethnic, and cultural minorities, such as American Indians, African Americans, Hispanics, Asian/Pacific Islanders, Lesbians, women with disabilities, and women who live in hard to reach communities in urban and rural areas. If the underlying Award authorizes the State to pay all allowable and allocable expenses of a contractor as of the effective date of that Award, then the State shall reimburse the Contractor for any allowable and allocable expenses of the Contractor that have been incurred by the Contractor since the proposed effective date of this Task Order Contract. If the underlying Award does not authorize the State to pay all allowable and allocable expenses of a contractor as of the effective date of that Award, then the State shall only reimburse the Contractor for those allowable and allocable expenses of the Contractor that are incurred by the Contractor on or after the effective date of this Task Order Contract, with such effective date being the later of the date specified in this Task Order Contract or the date the Task Order Contract is signed by the State Controller or delegee. 4. The Contractor shall provide breast and cervical cancer screening services to women during the term of this Task Order Contract. The Contractor shall also provide Women's Wellness Connection approved diagnostic services to all women found through a Women's Wellness Connection screening to be in need of diagnostic follow-up to the point of a definitive diagnosis. A woman shall be deemed as enrolled and screened only after the Contractor enters the complete case history in the eCaST database. The Contractor shall also perform Medicaid presumptive eligibility of women found to have cancer for enrollment in treatment under the Breast and Cervical Cancer Program as administered by Medicaid. The Contractor shall be paid in accordance with rates as outlined in this Task Order Contract. Rates are determined based on the type of screening performed (breast and or cervical) and the definitive diagnosis of such screening (normal, abnormal, cancer, pre -cancer or non-malignant). This payment shall cover: 1) enrollment and administrative services; 2) breast and or cervical cancer screening services provided by the Contractor or the Contractor's subcontractors, if any; and 3) all Women's Wellness Connection approved and medically indicated diagnostic. Payment pursuant to this Contract shall be made as earned, in whole or in part, from available federal funds in an amount not to exceed $2,000,000.00 Dollars and from available State funds in an amount not to exceed $2,600,000.00 Dollars for the purchase of Women's Wellness Connection services. To be attached to CDPHE Task Order v1.0 (11/05) contract template Page 1 of 3 Revised: 12/19/06 EXHIBIT A To receive compensation under this Task Order Contract, the Contractor shall submit a signed Monthly Invoice/Cost Reimbursement Statement in a format acceptable to the State. An Invoice/Cost Reimbursement Statement must be submitted within sixty (60) calendar days of the end of the billing period for which services were rendered. Expenditures shall be in accordance with the Statement of Work attached hereto as Exhibit B and incorporated herein. These items may include, but are not limited to, the Contractor's salaries, fringe benefits, supplies, travel, operating, indirect costs which are allowable, and other allocable expenses related to its performance under this Task Order Contract. Invoice/Cost Reimbursement Statements shall: 1) reference this Task Order Contract by its contract routing number, which number is located on page one of this Task Order Contract; 2) state the applicable performance dates; 3) state the names of payees; 4) include a brief description of the services performed during the relevant performance dates; 5) describe the incurred expenditures if reimbursement is allowed and requested; and, 6) show the total requested payment. Payment during the initial, and any renewal or extension, term of this Task Order Contract shall be conditioned upon affirmation by the State that all services were rendered by the Contractor in accordance with the terms of this Task Order Contract. Invoice/Cost Reimbursement Statements shall be sent to: Colorado Department of Public Health and Environment Prevention Services Division Attn: Grants Accounting Unit PSD/WWC/A-5 C/A -5 4300 Cherry Creek Drive South Denver, CO 80246 To be considered for payment, billings for payments pursuant to this Task Order Contract must be received within a reasonable time after the period for which payment is requested, but in no event no later than sixty (60) calendar days after the relevant performance period has passed. Final billings under this Task Order Contract must be received by the State within a reasonable time after the expiration or termination of this Task Order Contract; but in no event no later than sixty (60) calendar days from the effective expiration or termination date of this Task Order Contract. Unless otherwise provided for in this Task Order Contract, "Local Match", if any, shall be included on all billing statements as required by the funding source. The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless approved in writing by the appropriate federal agency. 5. Time Limit For Acceptance Of Deliverables. a. Evaluation Period. The State shall have ten (10) calendar days from the date a deliverable is delivered to the State by the Contractor to evaluate that deliverable, except for those deliverables that have a different time negotiated by the State and the Contractor. b. Notice of Defect. If the State believes in good faith that a deliverable fails to meet the design specifications for that particular deliverable, or is otherwise deficient, then the State shall notify the Contractor of the failure or deficiencies, in writing, within ten (30) calendar days of: 1) the date the deliverable is delivered to the State by the Contractor if the State is aware of the failure or deficiency at the time of delivery; or 2) the date the State becomes aware of the failure or deficiency. The above time frame shall apply to all deliverables except for those deliverables that have a different time negotiated by the State and the Contractor in writing pursuant to the State's fiscal rules. c. Time to Correct Defect. Upon receipt of timely written notice of an objection to a completed deliverable, the Contractor shall have a reasonable period of time, not to exceed ten (10) calendar days, to correct the noted deficiencies. If the Contractor fails to correct such deficiencies within ten (10) calendar days, the Contractor shall be in default of its obligations under this Task Order To be attached to CDPHE Task Order v1.0 (11/05) contract template Page 2 of 3 Revised: 12/19/06 EXHIBIT A Contract and the State, at its option, may elect to terminate this Task Order Contract or the Master Contract and all Task Order Contracts entered into pursuant to the Master Contract. 6. Notwithstanding the terms contained in Section 11, General Provisions, of the Master Contract, the parties agree to add the following language as new paragraphs six and seven: The financial management systems of the Contractor must meet the following standards: (i) Contractor shall expend and account for contract funds in accordance with generally accepted accounting principles (ii) Contractor shall maintain records that adequately identify the source/revenue and application/expenditure of funds. These records must contain information pertaining to contract awards, assets, liabilities, expenditures and income. (iii) Accounting records shall be supported by source documentation, including but not limited to cancel checks, paid bills, payroll, time and attendance records, and contract and subcontract documents. (iv) Contract funds shall be separately accounted for in Contractor's accounting records and shall not be commingled with Contractor's other funds. (v) Actual expenditures shall be compared with budgeted amounts. (vi) Costs allocated to this Contract shall be based upon relative benefits received. (vii) Applicable laws, regulations, and terms of the Contract will be followed in determining the reasonableness, allowability, and allocability of costs. Fiscal controls and accounting procedures of the Contractor must be sufficient to: (i) Permit the preparation of financial reports required by this Contract and preparation of financial statements; (ii) Allow Contractor's staff, in the normal course of performing their assigned functions, to prevent or detect misstatements in financial reporting or the loss of assets in a timely basis; (iii) allow for accurate, current, and complete disclosure of the financial activities made in accordance with the financial reporting requirements of the contract. 7. Notwithstanding the terms and conditions contained in Section 5, page 3, General Provisions, of this Task Order contract, the parties agree to add a new paragraph two which states the following: Option Letter. The State may increase or decrease the quantity of goods/services described in section/schedule/exhibit based upon the rates established in the Task Order Contract. If the State exercises the option, it shall provide written notice to Contractor as least 30 days prior to the end of the current contract term in a form substantially equivalent to Exhibit D. Delivery/performance of the goods/service shall continue at the same rates and terms. If the State exercises this option, the provisions of the Option Letter shall become part of and be incorporated into the original Task Order Contract. To be attached to CDPHE Task Order v1.0 (11/05) contract template Page 3 of 3 Revised: 12/19/06 EXHIBIT B STATEMENT OF WORK To Task Order Contract Dated 04/24/09- Contract Routing Number 09 FLA 01030 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. 1. The Contractor, in accordance with the terms and conditions of this contract, shall perform and complete, in a timely and satisfactory manner, all activities described in the approved Work Plan/Scope of Work that is attached hereto as Attachment B-1 and incorporated herein. To be attached to CDPHE Task Order v1.0 (11/05) contract template Page 1 of 1 Revised: 12/19/06 Attachment B -I STATEMENT OF WORK Project Period: June 30, 2009 through June 28, 2012. Background: The WOMEN'S WELLNESS CONNECTION program provides low-income, uninsured, and underserved women demonstrating lawful presence in Colorado access to timely, high -quality screening and diagnostic services to detect breast and/or cervical cancer at the earliest stages. It is a state -run program of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which is administered through the Centers for Disease Control (CDC). Services are available across Colorado. Direct Beneficiaries: Direct beneficiaries are women residing in Colorado who are unable to pay for breast or cervical screening services or have high insurance deductible that prevent screening and meet age, income and lawful presence requirements of the program, women of diverse ethnic backgrounds, women living in geographically isolated and medically underserved areas, those who are rarely or never screened for cervical cancer, or those that may have disabilities. Project Goals: 1. To deliver WOMEN'S WELLNESS CONNECTION services within the contractor's existing network of subcontractors. 2. To provide quality services to women receiving these screenings. 3. To increase annually the overall number of women who receive breast and cervical cancer screening services through the WOMEN'S WELLNESS CONNECTION program. Definitions: Breast Cancer Screen — Standard testing performed to determine the presence or non -presence of breast cancer. Standard screening tests include a clinical breast exam (CBE) and a mammogram. Cervical Cancer Screen — Standard testing performed to determine the presence or non -presence 1.1CWCCI- W W O W W C1.Service Delivery \SD Contract Page I of 13 Attachment B -I of cervical cancer. The standard screening test is a Pap test. Diagnostic Testing — Further testing used when a definitive diagnosis is unable to be determined by the results of prior screening tests. Network — Any provider site that works under the contractor name and receives fiscal and administrative assistance to do business. Subcontractor — An entity in the community that serve the contractor to meet the obligations of this contract. This will include services not available at the provider site agency or may include complex, technical services for diagnostic testing. Subcontractor agreements must be in writing and agreed and signed by both parties for particular services for a defined period of time. Deliverables: Under this arrangement, the contractor shall provide and perform the following: 1. Network a. The contractor must submit a list of agency contacts (Attachment B -1-A) annually. i. All staff changes during the contract year must be reported to the Department within 15 days. ii. This list must be updated annually, by September I, of each year. b. Ensure breast and cervical cancer screening services for WOMEN'S WELLNESS CONNECTION eligible women are performed by the contractor or through a subcontracted network of providers until a definitive diagnosis has been achieved. i. The contractor must maintain a network of subcontractors for its network and document this network by September 1, 2009. (Attachment B -1-B). 1:1CWCCI-W WC\W WC\Service Del ivery\SD Contract Page 2 of 13 Attachment B- I ii. This list must be updated annually, by September I, of each year. iii. Service performed by subcontractors shall: 1. Be performed in an outpatient setting to the extent possible. 2. Not exceed the Medicare reimbursement rate. 3. Not be charged to WOMEN'S WELLNESS CONNECTION women. 4. Be agreed upon in writing through the use of a contract or memorandum of understanding. c. The contractor must identify and support a WOMEN'S WELLNESS CONNECTION Coordinator at each screening site. i. The role of the coordinator will be a point of contact between the Contractor and the Department and will be considered the lead of the program at the agency level. ii. It will be expected that the coordinator will promote and distribute the communication of updates, policy changes, trainings, Core Performance Indicator reports, etc. throughout the agency and to necessary staff. iii. It is expected that the coordinator will be responsible for clinical quality performance at the agency level (as demonstrated in the Core Performance Indicator report) and update eCaST data as needed to keep the agency in compliance. iv. This role may also fill the need for a data contact at the agency. d. The contractor must identify and support a WOMEN'S WELLNESS CONNECTION Data Coordinator. J iC WCCI-W WC\ W W C\Service Delivery\SD Contract Page 3 of 13 Attachment B -1 i. The role of the data coordinator will be to ensure all information about women screened under WWC is entered into eCaST, the program's data collection and reimbursement tool. ii. It will be expected that the data coordinator will maintain data in eCaST that is up to date and meets Core Performance Indicators. iii. This role may work in tandem with the WWC Coordinator. 2. Enrollment The contractor must ensure that women screened under the WOMEN'S WELLNESS CONNECTION program: a. Meet WOMEN'S WELLNESS CONNECTION Program Eligibility Requirements (Attachment B -1-C). i. Eligibility guidelines may be updated during the period this scope of work is in effect. When new eligibility guidelines are adopted for implementation by WOMEN'S WELLNESS CONNECTION, the contractor will be notified and responsible for implementing necessary changes to the contractor workflow by a date determined by the Department. ii. Provide eligibility screenings and referrals in Spanish or other languages as requested. b. Meet Lawful Presence Requirements (per "Contract Special Provisions" and Attachment B -1-D). i. Obtain a signed affidavit and verify required documentation before services are rendered. 1.\CWCCI-W WC\W WC\Service Delivery\SD Contract Page 4 of 13 Attachment B- I ii. Document verification of lawful presence on the WWC Patient History Form and in eCaST for each woman the contractor will be requesting reimbursement. I. The "Verified Legal Presence" box must be checked in the electronic record in eCaST. a. Verification does not need to be updated once it has been documented and entered in eCaST. b. Failure to document in eCaST will result in non-payment of all services rendered. 2. If documents used to verify lawful presence expire at any point during a fiscal year under which WWC services were provided, the contractor is responsible for updating such documents. 3. Failure to properly verify identification or update such documents will void payment to the provider. 4. Electronic verification does not replace hard copy verification and providers must maintain verification in the medical record. iii. Refer to the Department of Revenue's web site for more specific information on Lawful Presence requirements at http ' wwxcrc5 uurc rn X11111OmcaSp. 3. Billing and Reimbursement a. The Contractor shall only request reimbursement from the State for a woman who meets eligibility, timeliness, performance and data requirements. i. Cases out of compliance with any of these requirements may be deemed ineligible for payment by the program. 1:\CWCCI-WWC\WWC\Service Delivery \SD Contract Page 5 of 13 Attachment B -I b. Reimbursement will be provided at the end of the case when a definitive outcome or diagnosis has been made and all data has been entered in eCaST. c. Reimbursement is determined by the outcome of the case. Payment will be determined at a global rate according to levels of care provide to the woman. (Attachment B -1-E). i. Cases that exceed 60 days in screening length and negatively affect the program's Core Performance Indicators may or may not be reimbursed at the discretion of the program. ii. Rates or the reimbursement process may be revised or updated during the period this scope of work is in effect. When changes are adopted for implementation by WWC, the contractor will be notified at least 60 days prior. d. It is expected that reimbursement will cover costs associated with: i. Enrollment of women into the WOMEN'S WELLNESS CONNECTION program; ii. Cancer screening services, including Pap test, clinical breast exam and mammogram; iii. Case management of abnormal findings; iv. Diagnostic services to the point of a definitive diagnosis, as necessary; v. Entry of all information into eCaST; and vi. Administrative procedures to place women with a positive diagnosis of 1\CWCCI-W WC\W WC\Service Delivery\SD Contract Page 6 of I3 Attachment B- I breast and/or cervical cancer onto Medicaid. e. At the discretion of the Department, charges for diagnostic services that exceed the average agency cost per woman may be reimbursed at a percent of the cost to the contractor on a quarterly basis. i. The Contractor will submit evidence of such additional expenses in November, February, May and August each year to the program. f. Data entered into eCaST will be the basis for calculating reimbursement for each woman screened. i. Data on women must be complete and entered in eCaST no later than the 14th of each month to be counted towards the Department's monthly cycle of reimbursement. ii. The contractor shall review eCaST reports, such as #17 - Missing Data, #10 — Procedures not Covered and #75 — Patients not Payable due to Missing Information to uncover women who may have missing essential information prior to the 14th of each month. 1. It is the responsibilities of the contractor to ensure its network of provider sites have entered all required data elements prior to the Department billing cycle. 2. Essential data elements missing from a woman's electronic record may make her ineligible for payment. g. One reimbursement check for all completed screenings that have met data quality standards and occurred in the prior 30 days will be sent to the Contractor each month. J \CWCCI-WWC\WWC\Service Delivery SD Contract Page 7 of 13 Attachment B -I i. The contractor will deal with WOMEN'S WELLNESS CONNECTION program staff directly on non-payment of women screened. If WOMEN'S WELLNESS CONNECTION staff is unable to rectify reimbursement, the contractor will work with the WOMEN'S WELLNESS CONNECTION fiscal officer to the point of satisfaction by both parties. 4. Service Delivery a. The Contractor shall follow and utilize all policy and guidelines according to the 2009-10 WOMEN'S WELLNESS CONNECTION Provider Toolkit as the standard of care when performing services related to breast and cervical cancer screening. i. The Provider Toolkit may be updated during the period this scope of work is in effect. When new documents/policy/guidelines or toolkit directives are adopted for implementation by WOMEN'S WELLNESS CONNECTION agencies, the contractor will be notified and responsible for implementing necessary changes by a date determined by the Department. 5. Performance Standards a. The contractor will meet or exceed established WOMEN'S WELLNESS CONNECTION Core Performance Indicators (Attachment B -1-F) and/or eCaST Reports #17, 84 & 85. i. Provider sites exceeding, meeting or not meeting indicators/reports will be contacted by the Department. 1. Sites not meeting indicators will have a program -approved quality improvement plan of action developed by the contractor and monitored by the Department. J ACWCCI-W WeAW WCAScrvice Delivery\SD Contract Page 8 of 13 Attachment B -I 2. Sites exceeding indicators will be recognized for good performance in a manner deemed appropriate by the Department. 6. Contractor Compliance and Site Review a. WOMEN'S WELLNESS CONNECTION will perform an annual review of the contractor and or the contractor's network of providers regarding performance with this contract. b. Performance will be based on, but not limited to: i. WOMEN'S WELLNESS CONNECTION Core Performance Indicators reports; ii. eCaST data reports, specifically Missing Data and Diagnostic Follow up reports as well as other reports; iii. Technical assistance with screening and diagnostic services; iv. Ability to refer positively diagnosed women to Medicaid treatment; v. Referral of women to the program's Treatment Navigator; and vi. Targeted screening goal attainment to date. c. WOMEN'S WELLNESS CONNECTION will provide feedback to the contractor within 30 days of the visit. i. A contractor exceeding, meeting or not meeting performance will be reported to the Director, Chronic Disease Branch. 1:\CWCC[-W Wc\W WC\Service Delivery SD Contract Page 9 of 13 Attachment B-1 1. Those contractors not meeting indicators will have a program - approved quality improvement plan of action developed by the contractor and monitored by the Department. 2. Those contractors meeting or exceeding performance will be positively recognized in a manner deemed appropriate by the Department. 7. ECaST System a. WOMEN'S WELLNESS CONNECTION will provide training on the data system to the contractor, its administration staff, fiscal staff and provider site staff as needed or requested by the contractor. i. Any changes to staff that are responsible for data entry of WOMEN'S WELLNESS CONNECTION information must be reported to the Department within 15 days. ii. New provider site staff must be trained by WOMEN'S WELLNESS CONNECTION on eCaST within 30 days of hire. b. Forms used to collect first level information will be electronically furnished by WOMEN'S WELLNESS CONNECTION. c. Security access to eCaST must be renewed annually by September l'. 8. Communication a. When corresponding with the Department, Contractors must use any and all privacy and security measures to protect the woman's personal health information. i. Accepted forms of submission include: J 1CWCCI-W WCAW WCAService Delivery \SD Contract Page 10 of 13 Attachment B-1 I. WWC identification number. 2. Mail or fax clearly marked "Confidential" 3. HIPAA compliant files transmitted via secure File Transfer Program (FTP) sites. b. The contractor and its network provider sites must attend meetings hosted by state staff to ensure compliance with this contract. i. The contractor will attend WOMEN'S WELLNESS CONNECTION sponsored conference calls and meetings, including but not limited to: 1. WOMEN'S WELLNESS CONNECTION Update Monthly Conference Calls; 2. ECaST Users Group Conference Calls; 3. Quarterly meetings with Medicaid staff; 4. WOMEN'S WELLNESS CONNECTION trainings that cover administrative, data and clinical program components; and 5. Other meetings upon request. ii. WOMEN'S WELLNESS CONNECTION staff will attend conference calls and meetings as needed and upon special request of the contractor. iii. WOMEN'S WELLNESS CONNECTION will include the contractor in all relevant program communications that may impact the success of this contract, including: I. Monthly electronic WOMEN'S WELLNESS CONNECTION Program Update; 2. ECaST Broadcast messages; 3. Special announcements to WOMEN'S WELLNESS JiCWCCI-WWC\WWC\Service Delivery \SD Contract Page II of 13 Attachment B -I CONNECTION providers; and 4. Other communications. 9. Professional Education and Trainings a. The contractor must participate in Department -sponsored trainings for staff responsible for WOMEN'S WELLNESS CONNECTION services. i. It is required that the WWC Coordinator, WWC Data Coordinator attends such trainings. ii. It will be expected that clinical providers attend clinical trainings. iii. Emphasis will be placed on core training areas of: 1. Enrollment 2. Clinical Management of Abnormal Findings 3. Clinical topics focused on breast and cervical care 4. Enrollment into Medicaid and 5. Others as determined by the department. iv. Attendance may be in person, via web -cast, or other educational technology implemented by the Department. b. The contractor will cover all costs for staff to attend trainings in person. 10. Medicaid Treatment for WOMEN'S WELLNESS CONNECTION Women Diagnosed with Cancer a. The contractor will refer women with a positive diagnosis of breast or cervical cancer to Medicaid. J:ACWCCI-W WCAW WCAService Delivery\SD Contract Page I2 of 13 Attachment B- I i. Contractor personnel must follow the STEP Enrollment Process and STEP Eligible Diagnosis List (Attachment B -1-G). ii. Women referred to Medicaid must be entered into eCaST within 24 hours of diagnosis. iii. Contractors will ensure applications are submitted to local Social Service agencies within 30 working days after diagnosis. iv. Women with a positive diagnosis can be referred to the WOMEN'S WELLNESS CONNECTION Treatment Navigator with the approval of the woman. b. Documents used in the process of enrolling women into Medicaid for treatment may be updated during the period this scope of work is in effect. When new documents are adopted for implementation by WOMEN'S WELLNESS CONNECTION, the contractor will be notified and responsible for implementing necessary changes by a date determined by the Department. J:ACWCCI-W WCvWWCAService Delivery\SD Contract Page 13 of 13 Attachment B -I -A WOMEN'S WELLNESS CONNECTION Agency Contact List ACI -. nc.y / Adr iini tr.ttivN Level Contact Intorniaticm PD�'L '.o.'5. .�d•i{j•�•C•.. O..iie.v ezi cT:fir:;Z::h•:7:!alf,7Y.'.r,,.?:iJ.•:..YA:7�.'7�i.r.:.•.'lPk'+:!.3 .r�.'Grh.•+.: ,^.lyd:a aa:r:...-. .a.. ..:.3 taatw AL d?33 P:tsar_-a:.Address Ag i cy Pronx ha - Aga.ct.-Faxt:'t 7be L•stsrcticr!s. w e .. :.•o r.,arte ar.k .CCX0C ✓}roue?a i3R AY' toe J' .r)Ct: fCrc t ti.7,4'. S N more that? O•'4' ce,r:taCt t t^e. F4eDSe .17te the re iuTc yrr2p Y t e1;41S. 'WWC Coorcinator Inc kid- on WWC email list DcCaSTuser This F the pnmary conta•:t f•_•r state'v WC: staff Knov.1. dg= -able in all program areas. Last Name Frst Name- Phone Num lar,,r Title Ern.ud Extension Mailing address Cityv =tats- Zip code - ._ar_ :c .a....:.'+ .3r{r'o33 *contract Administrator J Inc lud • on W'IC cvnad fist D eCaST kerson responsible fcr .sdrn in istratic•n •,f VON, c ontiri:t tfistNcrn Frst Name, Ph•.,n Number Title Email E?ttr:rni:n Mailing .address City aate Zip code » delete::: MCI' ::: ti'7c !: ma:Pr:J a:.Yf.7s 'Fiscal Payment Coord. D Include on iVC ernai ist D eCaS1 usw Person responsible for processing N W:= payments. Last Name first Warne_ Phone Number Titre Email Extension Mailing address City_ State Zip code _ dffe-ent ttun .clan • .,.a: cY sdd.?ss 'Agency Diector 3 Include on WWC email list 7 eCaST rrs�r Last Name Fist Nairn Prions Number Title Email Extension Mailing address t=roy :tats Zip code Lr d,15 ret 7....„ . 9t 2t { .1 a.st1a adatess Return by lax to Krh M.Crac ken at ' .M- a (' Add rnor= is•J•:•ncy Ar lrninrtrati': a Lam.' =f 7.c nt..:ts •)n set •teats sheet J.ICWCCt-WWC1WWC\Service Delivery\SD Contract Page I of I Attachment B -I -B WOMEN'S WELLNESS CONNECTION Agency Subcontractor List Subcontractor Verification — Fiscal Year 2009-2010 Instructions: Put an X in the boxes to verify that the listed agencies are your current subcontractors. Also, please verify the contact information for these subcontractors. List any missing subcontractors on the back of this page. Include name of subcontractor, address and city. Yes this is One of our Site Subcontractor Subcontractors Site Subcontractor EXAMPLE: County Public Health Memorial Hospital 1400 East Boulder Colorado Springs Penrad Mammography Center 3050 North Circle Drive Colorado Springs 11CWCCI-WWCW/W0Service Delivery\SD Contract Page I of I Attachment B -1-C WOMEN'S WELLNESS CONNECTION Eligibility Requirements 2009 Poverty Guidelines for the 48 Contiguous States and the District of Columbia Effective as ofJanuary 23, 2009 Persons in family (Household)* 250% of DHHS FEDERAL POVERTY GUIDELINES (FPL)** Size *** Monthly Annual I $2,256 $27,075 2 $3,035 $36,425 3 $3,815 $45,775 4 $4,594 $55,125 5 $5,373 $64,475 6 $6,152 $73,825 7 $6.931 $83,175 8 $7,710 $92,525 For families with more than 8 persons, add $9,350 annually or $779 monthly, for each additional person. *As defined by the Bureau of the Census for statistical purposes, a household consists of all the persons who occupy a housing unit (house or apartment), whether they are related to each other or not. If a family and an unrelated individual, or two unrelated individuals, are living in the same housing unit, they would constitute two family units, but only one household. **DHHS Federal Poverty Guidelines change annually by January. *** Size of Family Unit supported by Total Gross Household Income. Gross income is money made by individual BEFORE taxes. Source: Federal Register / Vol. 74, No. 14 / Friday, January 23, 2009: 7 1CW CCI-W WC1 W W C\Service Del,very Contract Page I of I Attachment B -1-D WOMEN'S WELLNESS CONNECTION Legal Presence Affidavit - English (Copy of agency letterhead) Verification of Lawful Presence AFFIDAVIT 1, swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): I am a United States citizen, or I am a Permanent Resident of the United States, or I am lawfully present in the United States pursuant to Federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. Signature Date J \CWCCI-W WC\W WC\Service Delivery\SD Contract Page I of 2 Attachment B -1-D WOMEN'S WELLNESS CONNECTION Legal Presence Affidavit - Spanish (Copy of agency letterhead) Verificacion de presencia legal DECLARACION Yo, afirmo bajo juramento y pena de perjurio que de conformidad con las leyes del estado de Colorado (marque una de las opciones siguientes): Soy ciudadano(a) de los Estados Unidos, o Soy residente permanente en los Estados Unidos, o Mi presencia en los Estados Unidos es legal de conformidad con las leyes federales. Entiendo que para dar cumplimiento a la ley, esta declaration bajo juramento es necesaria para solicitar la prestacion de un servicio publico. Entiendo que las leyes estatales exigen que compruebe que mi presencia en los Estados Unidos es legal con el fin de obtener la prestaciOn de un servicio publico. Asimismo, reconozco que hacer declaraciones falsas, ficticias o fraudulentas en esta declaration bajo juramento es un delito de perjurio de segundo grado de conformidad con el codigo penal de Colorado y el Estatuto revisado 18-8-503 del estado y que habra de constituir un delito penal por separado cada vez que se obtenga la prestacion de un servicio public() de manera fraudulenta. Firma Fecha 1:\CWCCI-W WC\ W WC\Service Delivery\SD Contract Page 2 of 2 Attachment B -1-E WOMEN'S WELLNESS CONNECTION Global Level Reimbursement Fee Structure LEVELI LEVEL2 LEVEL3 LEVEL4 Definition Clinical Breast Exam or pelvic exam only. Result is normal and requires no further action. Results of all tests are normal and require no further action. Enrollment and data entry fee added. Results are abnormal and require further non-invasive diagnostic testing. The definitive diagnosis is non- cancerous. Case management fee added. Results are abnormal, requiring additional invasive diagnostic testing. The definitive diagnosis may be cancer or non - cancer. An additional case management fee added. BREAST CANCER SCREEN Reimbursement $75 $190 $505 $1405 CERVICAL CANCER SCREEN Reimbursement $75 $135 $250 $650 Level rate of reimbursement is determined at the end of the case or up to 60 days as demonstrated by data entered into eCaST. Cases that exceed 60 days may or may not be reimbursed at the discretion of the Department.Attachment B -1-F Page 1 of 1 Attachment B -I -F WOMEN'S WELLNESS CONNECTION Core Performance Indicator Report 3a }1 W E C O w c co O s (1 a) 9 U c _ 3 a o a U C E too Q a) O tG O O U 6,1 to w 0.k Ln in •- U to v.) Zc w O U N UI uJ a a a 2 CFI C., 1 N :J �• h r .1 J)I s 3 «. N SC- , Cal A ^e yi 'o Z"; io a .) U L. Jam• •:1 • N Z I. . 1A } 1 t. 2 a a N • A r. Cr J:\CWCCI-WWC\WWC1Service Delivery\SD Contract Page I of I L re Ii e s Attachment B -1-G WOMENS WELLNESS CONNECTION Medicaid Enrollment STEP List / STEP 1 — Confirm Eligibility in BCCP & Close out in eCaST ai s. 4./§ ;k\ t0 o 10 cl \} Oll el 36 I *U \tl II 2� §2] _ §;2 ) ea §\\ ' );O. fl \ ap §!$ j \(n z\±\ \ ;�(®) C \{)/3 U �)\�\� \ \- v \ C —a° t co 00 6., Ct <=l:zSa2 \\o co \c}\ 72=6446. 32 / 011717 e Reminder a- Data entry into eCaST MUST be complete before proceeding. Reminder a- Eligibility must be confirmed by WWC staff BEFORE you call the PE Hotline. J'.ACWCCI-W WCAW WCAService Delivery\SD Contract the woman into PE. Once we confirm business day of receipt to confirm eli -o¢ O a if2 c 3 15 N u - o y L Q a 3 T Y N C O O O O d s O. c oco °A u G O U n. C Y Ni U S 3 o. u U Vi - w C L d O R q r44 N T O C u 0 .U. L L C id U a7 w ti U CC O td C OA •1J N _ > c`a °. o .C = w aL au E s o0 f L N O a N 7 ^ C) y N - C > £ O u w N y P ro - .• s d E O v C t T ' ' N E c ro O OP y C y a T > U C Ctl y• > C) > Eq 9 5 c — W R 3 U M R% L N S O C 8 O R• y C tr. N L . u O F E Z "le E W.00'^yL 0. = O = s a W 0 3 R. 2 „ U L , Us .0 :22 on available at your agency, at your local County O Ts O z 0 O c z0 ‘`...4 F o = C c O O L O O U . O CC M G N v c y co E E S O T 1 a E O a uL 3 ' 0J C 0 O N r W U N S U C/ F • V .O N a 0. E w c 9 «O. C .^ C -o u C UO O o U 9 O U O 2 a_ L a a 9 buq co S o. U-' ct O . N 9• y I. 'v v cud a 0. w d y O = oc^q 4 I. CC O y U 5. O N -O O C L � ,o O c 0 o U L 3 q .0 y tC T O Z d 0 la O. O O V 9 .E id • U y -a O O C..U., O'D C O �O cz ;L U a W � c. � is � O u C U U O o^ '. 3. 2 U 3 `O Q. w as cCl vie a a °f 0o aOU C C C '^ St ' S CJ O O m N .O' Q .— a+ A N O C .C .+ CJ N W• ..N. a U N O N c i E R» c N C C O �O = E a c 'U. a'�+ .s+ W .,4 m OU y O .O N u LL E R E .0 v U= ar a. N Y O O S O U R U >� S 'O Y .EL_ o 0 L °' tJ ai— bL c vwU _ u n o a= E b td O a >'° a - p �' C) {d U E Vi > 3 L «V] 0Ec�c $ Ca3 cep= L O O 'It' = c v -a T 'O td V' v S V W i .= L❑ O Z 28 i_ V V u u E 0 7 \CWCCI-W WC\W WC\Service Delivery\SD Con E 1. Call 303-388-2441 to let them know verbally that you are referring a client. By having the woman sign the form, this allows the En CC a 0 cat • C G_ N t a. Tat u C J t C 0 E d_ 0 rC L 2 N Z Q d > L d b➢ 0 0 CI. .f a CC d y U L N i C L Q d o • a dkr)L � T C? N rn O. C d o Cr, 0 x m o {l. A L- C-) O O M C) Ct 0. e Delivery \SD Contract J VCWCCI-W W CAW WCASe Attachment B -I -G ❑ For any questions about referring women, please call 303-388-2441. 'O O 'II � O 'p O T O 0 C . v 0 v �a T 3 p W T Nx C U 7 E N N T L r Y .O Q 2 Y a) t l•_ U! p E N v O .= N U v M L W T E L C) v > N N . C1.1 ell C C E E v E O .L. U w N w T a •5. ^n U N v § E ° U 3 3V. A O - 0 +N.. Y 4. C L C N � � — O T .O a) o•) O > '� L N 7 U U C L QUESTIONS? Call the WWC Quality and Compliance Coordinator at (303) 692-2323 0 O A J:CWCCI-W WCAW WCAService Delivery \SD Contract Attachment B -1-G Get Prior Approval From Colorado Women's Cancer Control Initiative (CWCCI) Nurse Consultant - - X X X 1 Diagnosis Not Covered by BCCP: Breast: Fibrocystic changes, Benign neoplasm of breast, Fibroadenoma, Papilloma, Radial Scar. Cervical: Human Papillomavirus (PV), Atypia, Cervical polyp, Cervical Intraepithelial Neoplasia I (CIN 1) / Mild dysplasia Low Grade Squamous Intraepithelial Lesions (LSIL), Invasive or In Situ cancer of the endometrium. W a a U C) m C.' v X X X X X. co U 233.0 174.0 — 174.9 �D M 00 rr', CJ O r^, r,`, Cd 622.1 en en N x I O O 00 .-r Presumptive Eligibility (PE) Action Breast Cancer Diagnosis Ductal Carcinoma In Situ (DCIS) Invasive Carcinoma (excludes lymphoma & melanoma) Atypical Ductal Hyperplasia, Atypical Lobular Hyperplasia Cystosarcoma phyllodes tumor Lobular Carcinoma In Situ (LCIS) Cervical Cancer Diagnosis CIN H / Moderate dysplasia CIN III / Severe dysplasia / Carcinoma in situ Invasive carcinoma of the cervix • Squamous cell carcinoma • Adenosquamous carcinoma • Adenocarcinoma of endocervix EXHIBIT C DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT ADD DIVISION -PROGRAM ACRONYMS DEPARTMENT OR AGENCY NUMBER CONTRACT ROUTING NUMBER ELIMINATE AU. INFORMATION APPEARING 1N RED LIMITED AMENDMENT FOR TASK ORDERS #* This Limited Amendment is made this **** day of *********, 200*, by and between the State of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of business is 4300 Cherry Creek Drive South, Denver, Colorado 80246, hereinafter referred to as the "State"; and, LEGAL NAME OF ENTITY, (Ieeal type of entity), whose address or principal place of business is Street Address, City, State & Zip Code, hereinafter referred to as the "Contractor". FACTUAL RECITALS The parties entered into a Master Contract, dated ******** **, ****, with contract routing number ** *** *****. Pursuant to the terms and conditions of the Master Contract, the parties entered into a Task Order Contract, dated ******** **, ****, with contract encumbrance number PO *** **********, and contract routing number ** *** *****,'insert the following, if pre% ion% anrcuilrncut(s). change order(s), renewal(%) horse been processed: as amended by) 'include all prey ions amend mentts), change order(s), renewal(%) and their routing numbersf, !insert the following if previous amendtnent(s), change order(s). renewal(s) hal e been processed: collectively] referred to herein as the "Original Task Order Contract, whereby the Contractor was to provide to the State the following: IBriefly describe shat the Contractor was to do under the Original Task Order Contract - indent this paragraph] [Please choose one of the following four options and delete the other three options not selected The State promises to 'choose one and delete the of hell increase/decrease the amount of funds to be paid to the Contractor by Dollars, ($*.**) during the current term of the Original Task Order Contract in exchange for the promise of the Contractor to perform the 'choose one and delete the other) increased/decreased work under the Original Task Order Contract. The State promises to pay the Contractor the sum of ********** Dollars, ($*.**) in exchange for the promise of the Contractor to continue to perform the work identified in the Original Task Order Contract for the renewal term of **** years/months, ending on ******** **, ****. The State promises to 'choose one and delete the others increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars, f$*.**) for the renewal term of ****'choose one and delete the other] years/months, ending on ******** **, ****, in exchange for the promise of the Contractor to perform the 'choose one and delete the others increased/decreased work described herein. The State hereby exercises a "no cost" change to the !choose those that apple and delete those that don't apply' budget, specifications within the Statement of Work, project management/manager identification, notice address or notification personnel , or performance period within the (choose one and delete the other' current term of the Original Task Order Contract or renewal term of the Original Task Order Contract. Page 1 of 4 Rev 4/3/09 EXHIBIT C NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: t. Consideration for this Limited Amendment to the Original Task Order Contract consists of the payments and services that shall be made pursuant to this Limited Amendment, and promises and agreements herein set forth. 2. It is expressly agreed to by the parties that this Limited Amendment is supplemental to the Original Task Order Contract, contract routing number ** *** *****, (insert the following language here if previous amendment(s), change order(s), renewals) have been processed! as amended by 'include all previous amendment(s), change order(s), renewals) and their routing numbers', 'insert the following word if previous a mend menus), change order(s). rene,tat(.) base been pruc•essed. otherwise delete "collectively"(collectively referred to herein as the Original Contract, which is by this reference incorporated herein. All terms, conditions, and provisions thereof, unless specifically modified herein, are to apply to this Limited Amendment as though they were expressly rewritten, incorporated, and included herein. 3. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified, altered, and changed in the following respects only: (Please choose one of the following three options and delete the two options not selected( A. (Use this paragraph when changes to the funding level of the Original Task Order Contract occur during the current term of the Original Task Order Contract I This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment is for the current term of ********* ** ****, through and including ********* **, ****. The maximum amount payable by the State for the work to be performed by the Contractor during this current term is 'choose one and delete the other! increased/decreased by ********** Dollars, f$*.**) for an amended total financial obligation of the State of ********** DOLLARS, ($*.**). (Delete the following sentence if not applicable in your situation! The revised Statement of Work is incorporated herein by this reference and identified as "Attachment *". (Delete the following sentence if not applicable in your situation I The revised Budget is incorporated herein by this reference and identified as "Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. 'Use this paragraph when the Original Task Order Contract will be renewed for another term! This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment is for the renewal term of ********* **, ****, through and including ********* **, ****. The maximum amount payable by the State for the work to be performed by the Contractor during this renewal term is ********** Dollars, f$*.**) for an amended total financial obligation of the State of ********** DOLLARS, ($*.**). IDelete the following sentence if not applicable in your situation! The revised Statement of Work is incorporated herein by this reference and identified as "Attachment *". (Delete the following sentence if not applicable in sour situation) The revised Budget is incorporated herein by this reference and identified as "Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. (Use this paragraph when there are "no cost changes" to the Budget, the specifications within the original titatemcnt of Worh, allowable contract provisions as noted, or performance period.( This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment )choose those that apply and delete those that don't( modifies the Budget in (identify location in contracts, modifies the Statement of Work in I identify location in Page 2 of 4 Rev 4/3/09 EXHIBIT C contract', modifies the project management/manager identification in'identitlocation in contact', modifies the notice address or notification personnel in 'identify location in contract 1, modifies the period of performance in Iidentife location in contract' of the Original Task Order Contract. The revised 'choose those that appl and delete those that don't' Budget, Statement of Work, project management/manager identification, notice address or notification personnel is incorporated by this reference and identified as Exhibit * or Attachment *-*. I If you are ehanging the performance period, choose the following two sentences or delete both sentences' The period of performance of the choose one and delete the other' current/renewal term is hereby 'choose one and delete the other extended/reduced by ***** (*) months changing the current ending date from ********* ** **** to ********* ** ****. The revised period of performance is ********* ** **** through and including ********* ** **** The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. 4. The effective date of this Limited Amendment is ******** ** **** or upon approval of the State Controller, or an authorized delegate thereof, whichever is later. 5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General Provisions of the Original Task Order Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Limited Amendment and any of the terms and provisions of the Original Task Order Contract, the terms and provisions of this Limited Amendment shall in all respects supersede, govern, and control. The Special Provisions and other terms and conditions of the Master Contract shall always control over other provisions of the Original Task Order Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Master Contract concerning the absence of personal interest of state of Colorado employees and the certifications in the Special Provisions relating to illegal aliens are presently reaffirmed. 6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. Page 3 of 4 Rev 4/3/09 EXHIBIT C IN WITNESS WHEREOF, the parties hereto have executed this Limited Amendment on the day first above written. * Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's behalf and acknowledge that the State is relying on their representations to that effect. CONTRACTOR: STATE: [LEGAL NAME OF CONTRACTOR) STATE OF COLORADO (Legal type of entity) Bill Ritter, Jr. Governor By: Signature of Authorized Officer Print Name of Authorized Officer Print Title of Authorized Officer For the Executive Director DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Signatory avers to the State Controller or that Contractor has not begun performance or that a Statutory Violation waiver has been requested under Fiscal Rules PROGRAM APPROVAL: By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until signed and dated below by the State Controller or delegate. Contractor is not authorized to begin performance until such time. If Contractor begins performing prior thereto, the State of Colorado is not obligated to pay Contractor for such performance or for any goods and/or services provided hereunder. By: Date: STATE CONTROLLER David J. McDermott, CPA Page 4 of 4 Rev 4/3/09 Exhibit D SAMPLE OPTION LETTER Date: State Fiscal Year: I Option Letter No. CLIN Routing # 1) OPTIONS: Choose all applicable options listed in §1 and in §2 and delete the rest. a. Option to renew only (for an additional term) b. Change in the amount of goods within current term c. Change in amount of goods in conjunction with renewal for additional term d. Level of service change within current term e. Level of service change in conjunction with renewal for additional term f. Option to initiate next phase of a contract 2) REQUIRED PROVISIONS. All Option Letters shall contain the appropriate provisions set forth below: a. For use with Options 11a -e): In accordance with Section(s) of the Original Contract routing number between the State of Colorado, Department of Public Health and Environment, and Contractor's Name, the State hereby exercises its option for an additional term beginning Insert start date and ending on Insert ending date at a cost/price specified in Section , AND/OR an increase/decrease in the amount of goods/services at the same rate(s) as specified in Identify the Section, Schedule, Attachment, Exhibit etc. b. For use with Option 1(f), please use the following: In accordance with Section(s) of the Original Contract routing number between the State of Colorado, Insert Name of Department or Higher Ed Institution , and Contractor's Name, the State hereby exercises its option to initiate Phase indicate which Phase: 2, 3, 4, etc for the term beginning Insert start date and ending on Insert ending date at the cost/price specified in Section c. For use with all Options 1(a -f): The amount of the current Fiscal Year contract value is increased/decreased by $ amount of change to a new contract value of Insert New $ Amt to as consideration for services/goods ordered under the contract for the current fiscal year indicate Fiscal Year. The first sentence in Section is hereby modified accordingly The total contract value including all previous amendments, option letters, etc. is Insert New $ Amt. 3) Effective Date. The effective date of this Option Letter is upon approval of the State Controller or whichever is later. STATE OF COLORADO Bill Ritter, Jr. GOVERNOR Department of Public Health and Environment By: Lisa Ellis, Purchasing & Contracts Unit Director Date: ALL CONTRACTS REQUIRE APPROVAL BY THE STATE CONTROLLER CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until signed and dated below by the State Controller or delegate. Contractor is not authorized to begin performance until such time. If Contractor begins performing prior thereto, the State of Colorado is not obligated to pay Contractor for such performance or for any goods and/or services provided hereunder. STATE CONTROLLER David J. McDermott, CPA By: Donald Rieck Date: Page 1 of 1 Effective Date: 1/6/09 Bill Ritter, Jr., Governor James B. Martin, Executive Director Dedicated to protecting and improving the health and environment of the people of Colorado 4300 Cherry Creek Dr. S. Laboratory Services Division Denver, Colorado 80246-1530 8100 Lowry Blvd. Phone (303) 692-2000 Denver, Colorado 80230-6928 TDD Line (303) 691-7700 (303) 692-3090 Located in Glendale, Colorado http://www.cdphe.state.co.us June 29, 2009 Dear Women's Wellness Connection Contractor: Enclosed is the signed, fully executed contract with the Women Wellness Connection Service Delivery program. Please note that if any work was performed prior to the date signed by the State Controllers, the State of Colorado is not obligated to pay for the goods services provided. If you have question 4r need additional information, feel free to contact me at (303) 692-2367 STATE OF COLORADO Genevieve Row Center for Health Living and Chronic Disease Prevention Grants Accounting Fiscal Officer Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver, CO 80246-1530 Cc: File Colorado Department of Public Health and Environment Hello