HomeMy WebLinkAbout20240326.tiffRESOLUTION
RE: APPROVE STANDARD FORM FOR CASE MANAGEMENT AGENCY (CMA) SERVICE
AGREEMENT TERMS AND CONDITIONS, AND PROVIDER LIST, BETWEEN
DEPARTMENT OF HUMAN SERVICES AND VARIOUS PROVIDERS, AND
AUTHORIZE CHAIR TO SIGN AGREEMENTS CONSISTENT WITH SAID FORM
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 Standard Form for Case Management
Agency (CMA) Service Agreement Terms and Conditions, and a Provider List, between the
Department of Human Services and the various providers as shown on the attached list, and
WHEREAS, after review, the Board deems it advisable to approve said standard form and
provider list, copies of which are attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, that the Standard Form for Case Management Agency (CMA) Service
Agreement Terms and Conditions, and Provider List, between the Department of Human Services
and the various providers as shown on the attached list, be, and hereby are, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign any agreements consistent with said standard form.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 12th day of February, A.D., 2024.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: se&itio :
Weld County Clerk to the Board
tY( .u)otA ra
Deputy Clerk to the Board
Perry L. B; ck, Pro-Tem
Mike Freeman
ounty Attorney
Date of signature: 21221 Z `7
2024-0326
HR0096
cc: HSD, CA' 644), c-r$(EG), AcT(cP/cD)
03/11/29
BOARD OF COUNTY COMMISSIONERS
PASS -AROUND REVIEW
PASS -AROUND TITLE: Case Management Agency Service Agreement Terms and Conditions Template and
State General Fund Provider List
DEPARTMENT: Human Services DATE: February 6, 2024
PERSON REQUESTING: Jamie Ulrich, Director, Human Services
Brief description of the problem/issue: On March 1, 2024, the Weld County Department of Human Services will be begin
serving as the region's Case Management Agency (CMA) as a result of an awarded Request for Proposal (RFP) through
the Colorado Department of Health Care Policy & Financing (HCPF). In order to offer services to clients as the CMA, the
Department is requesting approval of the CMA Service Agreement Terms and Conditions template and State General Fund
(SGF) Vendor List.
The Service Agreement and Exhibit A have been approved by Legal (B. Howell) and reflect a term date of March 1, 2024
through June 30, 2024 and may be extended upon written agreement by both parties. The following information is attached
for your reference:
1. CMA Service Agreement Terms and Conditions Template
2. Exhibit A — HIPPA Business Associate Agreement
3. Exhibit B — Scope of Services and Rates
4. SGF Vendor List for SFY 2023-24
What options exist for the Board?
Approval of the Case Management Agency Service Agreement Template and SGF Vendor List.
Deny approval of the Case Management Agency Service Agreement Template and SGF Vendor List.
Consequences: WCDHS will not have contracts with providers.
Impacts: WCDHS will not be able to serve the individuals on our caseload.
Costs (Current Fiscal Year / Ongoing or Subsequent Fiscal Years):
Total cost = State approved rates for services.
Pass-thru funding from the Colorado Department of Health Care Policy & Financing (HCPF).
Recommendation:
• Approval of the Case Management Agency Service Agreement Terms and Conditions Template and listed State
General Fund Vendor List, and authorize the Chair to sign subsequent agreements.
Support Recommendation Schedule
Place on BOCC Agenda Work Session Other/Comments:
Perry L. Buck, Pro-Tem
Mike Freeman
Scott K. James
Kevin D. Ross, Chair
Lori Saine
Pass -Around Memorandum; February 6, 2024 — NOT IN CMS
2024-0326
Y2
Case Management Agency (CMA)
Service Agreement Terms and Conditions
This Service Agreement (SA) is made this day , by and between
Weld County Department of Human Services, hereinafter referred to as "CMA", having its
principal place of business at 315 North t It Avenue, Greeley, Colorado 80631, and
«PROVIDER» (name), hereinafter referred to as the "VENDOR," whose business address is
«ADDRESS», «ADDRESS_2». NOW THEREFORE, in consideration of the promises and
covenants contained herein, the parties agree as follows:
I. Work and Payment
The VENDOR should not commence services under this Agreement until Services have been
approved in the individual's Service Plan. Services to be provided are detailed in the Individual's
State Supported Living Services (SLS) or OBRA Service Plan which dictates the type of service
as well as timing and frequency of service to be performed. Rates paid for State SLS and OBRA
services can be found on the State Health Care Policy and Financing Website
https://hcpf.colorado.gov/provider-rates-fee-schedule see State General Fund Programs Direct
Service Rates Fee Schedule. The VENDOR shall include in their monthly invoice the date and
duration of services performed.
Specific work performance expectations that are deemed appropriate and necessary in order to
receive compensation for the work must meet specified State Regulations. Services covered in
this agreement are listed in Exhibit B, Scope of Services and Rates. The VENDOR affirms the
following requirements are met, as defined by the State of Colorado:
The service to be delivered shall meet all applicable state licensing requirements for the
performance of the support or service being provided.
Certificate: The service to be delivered shall meet all applicable state certification
requirements for the performance of the support or service being provided and program
approval.
Electronic Visit Verification (EVV) is not a requirement for billing State SLS / OBRA services.
More information can be found on the HCPF website https://hcpf.colorado.gov/electronic-visit-
verification-program-manual#coEV VX
II. Intent of the Parties:
It is the expressed intent of the parties that the Contractor is a VENDOR and not the agent,
employee, or servant of CMA and that:
a. The VENDOR does not have the express or implied authority to act for CMA or to bind
CMA to any agreements, liability, or understanding except as expressly set forth herein.
b. The VENDOR shall be accountable to CMA for the ultimate results of its actions but shall
not be subject to direction and control of CMA herein.
c. Neither the VENDOR nor any agent or employee of the VENDOR shall be or shall be
deemed to be an agent or employee of CMA.
d. The VENDOR shall pay when due all required employment taxes and Income Tax
Withholdings, including all Federal and State Income Tax and Local Tax on any monies paid
pursuant to this service authorization.
e. The VENDOR acknowledges that the VENDOR and its employees are not entitled to
unempbyment insurance benefits unless the VENDOR, or a Third Party provides such
coverage, and that CMA does not pay for or otherwise provide such coverage.
f. The VENDOR shall provide and keep in force Worker's Compensation and show proof of
such inirance; and unemployment compensation insurance in the amounts required by law
and shat be solely and entirely responsible for the acts of the VENDOR, its employees, and
agents. The VENDOR shall furnish CMA with written certification of the existence of such
coverage prior to the finalization of service authorization provisions.
III. VENDOR Responsibilities:
a. COMPLIANCE WITH THE LAW: The VENDOR agrees to perform its duties and
obligations hereunder in strict conformity with relevant federal law, all pertinent federal
regulations promulgated pursuant to federal law, the Home and Community -Based Services
for Persons with Developmental Disabilities Act; 10 Code of Colorado Regulations (CCR)
2505-16 8.500; 10 CCR 2505-10 8.600 Colorado Revised Statute (CRS); Title 25.5 Article
10 et seq., relevant State law, and all pertinent regulations of the Colorado Department of
HumanServices, Colorado Department of Health Care Policy and Financing, and Colorado
Department of Public Health and Environment, as they currently exist or may hereafter be
amendmi.
b. LICENSES AND CERTIFICATIONS: The VENDOR represents and warrants to CMA that
it and it employees have the requisite training, skills, experience, qualifications, all
necessary provider numbers, licenses, certifications, approvals, etc. required to properly
provide≤the services or goods covered by this authorization.
c. RECORDS: The VENDOR shall maintain a complete file of all records, communications,
documents, and other written materials that pertain to the operation of programs or the
delivery of services under this SA and shall maintain such records for a period of six (6)
years alter the date of termination of this SA as per State requirements, or for such further
period as may be necessary to resolve any matters which may be pending. All files shall be
kept at lie VENDOR's place of business, and the VENDOR shall furnish copies of such
files, or -portions thereof, as requested by CMA or its designee.
d. INSPECTIONS AND PERFORMANCE MONITORING: The VENDOR shall permit
CMA, te State of Colorado, the Colorado Department of Health Care Policy and Financing,
the U.S. Department of Health and Human Services, and any other duly authorized agent or
governmental agency (including the Medicaid Fraud Control Unit) to monitor all activities
authorized under this SA. Such monitoring may consist of internal evaluation procedures,
examination of data, formal audit, on -site checking, or any other reasonable procedure. Any
amount which have been paid by CMA, and which are found to be improper in accordance
with the terms of this SA shall be immediately returned to CMA or may be withheld from
future payments. Services rendered through State SLS are subject to inspection and recovery
by the Department pursuant to 10 C.C.R. 2505-10 Section 8.076.
e. ASSIGNMENT/DELEGATION/SUBCONTRACTORS: The VENDOR shall not assign,
delegate, nor subcontract services in this SA without the express prior written consent of
CMA.
f. INSURANCE:
i. The VENDOR agrees that it will keep in force an insurance policy or policies, issued
by a company authorized to do business in Colorado, in the kinds and minimum
amounts specified below unless specifically waived herein. In the event of cancellation
of any such coverage, the VENDOR shall immediately notify CMA of such
cancellation.
ii. The VENDOR shall have CMA and State of Colorado Health Care Policy and
Financing listed as "Additional Insured" on VENDOR's insurance policies.
iii. Standard Worker's Compensation and Employers' Liability as required by State
statute, including occupational disease, covering all employees on or off the work site
acting within the course and scope of their employment.
iv. General, Personal Injury, Professional, Automobile Liability (including bodily injury,
personal injury, and property damage) minimum coverages:
v. Occurrence basis policy: combined single limit of $1,000,000 or Claims -Made policy:
combined single limit of $1,000,000; plus, an endorsement, certificate, or other
evidence that extends coverage two years beyond the performance period of the service
authorization.
vi. Annual Aggregate Limit policy: Not less than $1,000,000 plus an agreement that the IC
will purchase additional insurance to replenish the limit to $1,000,000 if claims reduce
the annual aggregate below $1,000,000.
vii. The insurance shall include provisions preventing cancellation without thirty (30)
calendar days prior written notice to CMA by certified mail.
viii. The VENDOR shall provide certificates of adequate insurance coverage to CMA
within ten (10) days of receipt of this service authorization.
IV. Payment for Services and Term:
a. This contract shall be for a term commencing March 1, 2024 through June 30, 2024 and
may be extended upon written agreement of both parties.
b. Monthly Invoicing: The VENDOR shall invoice CMA within four (4) working days of the
end of the month in which the services were performed, except at the end of the fiscal year
when invoices are due two (2) working days from the end of the fiscal year. Invoices
received within this time frame will be paid Net 30 unless otherwise noted on the invoice.
Invoices may be sent via email to wccmabilling@weld.gov
c. Vendor must include the following detail on invoices in order to be paid for services:
i. Name of individual in services
ii. Dates of Service
iii. For services paid in 15 -minute increments, invoice must show the amount of time
services were provided in hours or 15 -minute increment
iv. Rate per 15 -minute increment or Rate per hour (per Medicaid fee schedule)
v. Total Amount Due
vi. "No shows" are not billable to Medicaid and will not be reimbursed. Do not include
"No shows" in your billing ("No shows" include family cancelling or provider
cancelling)
d. In order to comply with HCPF State General Funds reporting requirements, no invoices
received from the VENDOR after July 3, 2024, for Fiscal Year July 1, 2023 thru June 30,
2024 will be accepted or paid by CMA, the date of July 3, 2024 is subject to change pending
Fiscal Year 23-24 holiday schedule.
e. Services may be increased or decreased during the term of this agreement by either party due
to increased or decreased State funding levels or adjustments to service levels, with the
agreement by both parties.
f. In the event that overpayments are made by CMA due to the VENDOR's omission, error,
fraud, or defalcation; or in the event that the State or Federal government seeks to recover
from CMA any sums of money based upon a claim on behalf of the VENDOR after said
funds have been paid to the VENDOR, the VENDOR shall immediately reimburse such
funds to CMA as allowed by law. The parties understand and agree that CMA shall have the
right to offset against payments due to the VENDOR hereunder, or by other legal means
recover any debts owed by the VENDOR to CMA or to the State.
V. General Terms and Conditions:
a. TERMINATION: Except as otherwise agreed in Section I, if the VENDOR refuses or fails
to perform any of the provisions of this SA in a timely manner, CMA may notify the
VENDOR in writing of nonperformance and may terminate VENDOR's right to proceed
with the SA. In addition, either party shall have the right to terminate this SA, without cause,
by giving the other party 30 days written notice. If notice is so given, this SA shall terminate
on the a cpiration of the thirty (30) days, and the liability of the parties hereunder for further
performance of the terms of this agreement shall thereupon cease, but the parties shall not be
released from the duty to perform their obligations up to the date of termination.
b. COMPLETE SERVICE AUTHORIZATION: This SA contains the entire agreement of the
parties.
c. INDEMNIFICATION: To the extent authorized by law, the VENDOR shall indemnify,
save, and hold harmless CMA, its employees, and agents against any and all claims,
damages, liability, and court awards including costs, expenses, and attorney fees incurred as
a result of any act or omission by the VENDOR or its employees, agents, subcontractors, or
assignees pursuant to the terms of this SA.
d. NON-DISCRIMINATION: The VENDOR agrees to comply with the letter and spirit of all
applicable State and federal laws respecting discrimination and unfair employment practices.
e. CONFIDENTIALITY OF RECORDS: The VENDOR shall protect the confidentiality of all
records containing personal identifying information that are maintained in accordance with
this SA. No such information shall be released except for program administration purposes or
with the subject individual's prior written consent.
f. CONFLICT OF INTEREST: The VENDOR shall fully disclose to CMA any relationship(s)
it has with a third party where such relationship is in opposition or conflict to its relationship
with CMA under this SA.
g. Health Insurance Portability & Accountability Act of 1996 ("HIPAA"). Federal law
governing the privacy of certain health information requires a "Business Associate" service
authorization between CMA and the VENDOR. 45 CFR Section 164.504(e). Attached and
incorporated herein by reference as Exhibit A is a HIPAA Business Associate Addendum for
HIPAA compliance.
h. BACKGROUND CHECKS: As per C.R.S. 27-90-111, the VENDOR shall conduct
background (criminal record) and reference checks prior to hiring staff and volunteers or
contracting with other providers. The VENDOR shall not employ, contract with, or accept
volunteer services from individuals who would have unsupervised contact with or access to
persons receiving services under this service authorization, or their property and who have
been convicted of abuse, neglect, or mistreatment of a child, adult or person receiving
services, or of a misdemeanor or felony involving physical harm or violence to another
individual, or distribution of controlled substances.
i. CONTRACTS FOR SERVICE - ILLEGAL ALIENS: The VENDOR shall not knowingly
employ or contract with illegal aliens to perform work under this service authorization or
enter ieeo a contract with a subcontractor that fails to certify to VENDOR that the
subcontractor knowingly does not employ or contract with illegal aliens to perform work
under this service authorization. The VENDOR, if a natural person eighteen (18) years of age
or older, hereby swears or affirms under penalty of perjury that he or she (i) is a citizen or
otherwise lawfully present in the United States pursuant to federal law, (ii) shall comply with
the provisions of CRS 24-76.5-101 et seq. and (iii) shall produce identification required by
CRS 24-76.5-103 prior to the effective date of this service authorization.
j. If there is a dispute, VENDORs are to follow Section 25.5-10-212 CRS,
k. The VENDOR agrees to abide by the following CMA policies and procedures located on the
CMA website at https://www.weld.gov/Government/Departments/Human-Services/Area-
Agency-on-Aging-AAA
i. Critical Incidents
ii. Mistreatment
iii. Human Rights Committee (HRC)
1. FEDERAL FALSE CLAIMS ACT 31 US Code 3729: The VENDOR, its employees,
subcontractors, and agents shall comply with the Federal False Claims Act. Violations of the
False Claims Act such as false claims or attempts to defraud health care programs should be
promptly reported, investigated, and remedied, as appropriate and required by law. Detailed
information regarding the False Claims Act and CMA's policy can be found on the CMA
website.
The parties have caused their duly authorized representatives to sign this Service Authorization
Agreement stated above:
CMA:
ATTEST: BOARD OF COUNTY COMMISSIONERS
Clerk to the Board WELD COUNTY, COLORADO
BY:
Deputy Clerk to the Board
Kevin D. Ross, Chair
VENDOR:
Name
Address
City, State Zip
By:
Name, Title
Date:
Exhibit A
CMA
HIPAA BUSINESS ASSOCIATE AGREEMENT
This Business Associate Agreement ("Agreement") is part of federal and state
requirements of CMA For purposes of this Agreement, CMA is referred to as "Covered Entity"
or "CE" and VENDOR is referred to as the "Business Associate" or "Associate." The Associate
performs, a- assists in the performance, of a function or activity, or provides services of a type
for CMA that makes the Associate a "Business Associate" for purposes of the HIPAA privacy
regulations.
The CE may disclose protected health information to the Associate in conjunction with the
function, activity, or services performed or provided by the Associate. The CE and the
Associate desire to enter into an agreement as required by the HIPAA privacy regulations to
provide satisfactory assurance to CMA that the Associate will appropriately safeguard that
protected health information (PHI).
RECITALS
A. CE and Associate intend to protect the privacy and provide for the security of PHI
disclosed to Associate pursuant to this Agreement in compliance with the Health
Insurance Portability and Accountability Act of 1996, 42 U.S.C. §1320d — 1320d-8
("HIPAA"), as amended by the American Recovery and Reinvestment Act of 2009
("ARRA")/HITECH Act (P.L. 111-005), and its implementing regulations promulgated
by the U.S. Department of Health and Human Services, 45 C.F.R. Parts 160, 162 and
164 (the "HIPAA Rules") and other applicable laws, as amended.
B. As part of the HIPAA Rules, the CE is required to enter into an agreement containing
specific requirements with Associate prior to the disclosure of PHI, as set forth in, but
not limited to, Title 45, Sections 160.103, 164.502(e) and 164.504(e) of the Code of
Federal Regulations ("C.F.R.") and contained in this Agreement.
The parties agree as follows:
1. Term. Except as otherwise provided for herein, this Agreement will continue in full
force and effect through the term of any function, activity, or services performed or provided
by the Associate.
2. Definitions.
a. Except as otherwise defined herein, capitalized terms in this Agreement shall
have the definitions set forth in the HIPAA Rules at 45 C.F.R. Parts 160, 162 and 164, as
amended. In the event of any conflict between the mandatory provisions of the HIPAA Rules
and the provisions of this Agreement, the HIPAA Rules shall control.
b. "Protected Health Information" or "PHI" means any information, whether oral
or recorded in any form or medium: (i) that relates to the past, present, or future physical or
mental condition of an individual; the provision of health care to an individual; or the past,
present, or future payment for the provision of health care to an individual; and (ii) that
identifies the individual or with respect to which there is a reasonable basis to believe the
information can be used to identify the individual and shall have the meaning given to such
term under the HIPAA Rules, including, but not limited to, 45 C.F.R. Section 164.501.
c. "Protected Information" shall mean PHI provided by CE to Associate or created,
received, maintained, or transmitted by Associate on CE's behalf. To the extent Associate is a
covered entity under HIPAA and creates or obtains its own PHI for treatment, payment, and
health care operations, Protected Information under this Agreement does not include any PHI
created or obtained by Associate as a covered entity and Associate shall follow its own policies
and procedures for accounting, access and amendment of Associate's PHI.
3. Obligations of Associate.
a. Permitted Uses. Associate shall not use Protected Information except for the
purpose of performing Associate's obligations as permitted under this Agreement. Further,
Associate shall not use Protected Information in any manner that would constitute a violation
of the HIPAA Rules if so used by CE, except that Associate may use Protected Information: (i)
for the proper management and administration of Associate; (ii) to carry out the legal
responsibilities of Associate; or (iii) for Data Aggregation purposes for the Health Care
Operations of CE. Associate agrees to defend and indemnify the CE against third party claims
arising from Associate's breach of this Agreement.
b. Permitted Disclosures. Associate shall not disclose Protected Information in any
manner that would constitute a violation of the HIPAA Rules if disclosed by CE, except that
Associate may disclose Protected Information: (i) in a manner permitted pursuant to this
Agreement; (ii) for the proper management and administration of Associate; (iii) as required by
law; (iv) for Data Aggregation purposes for the Health Care Operations of CE; or (v) to report
violations of law to appropriate federal or state authorities, consistent with 45 C.F.R. Section
164.502(j)(1).
c. Appropriate Safeguards. Associate shall implement appropriate safeguards as
are necessary to prevent the use or disclosure of Protected Information other than as permitted
by this Agreement. Associate shall comply with the requirements of the HIPAA Security Rule
at 45 C.F.R. Sections 164.308, 164.310, 164.312, and 164.316. Associate shall maintain a
comprehensive written information privacy and security program that includes administrative,
technical, and physical safeguards appropriate to the size and complexity of the Associate's
operations and the nature and scope of its activities. Associate shall review, modify, and update
documentation of its safeguards as needed to ensure continued provision of reasonable and
appropriate protection of Protected Information.
d. Reporting of Improper Use or Disclosure. Associate shall report to CE in
writing any use or disclosure of Protected Information other than as provided for by this
Agreement within five (5) business days of becoming aware of such use or disclosure.
e. Accounting Rights. Associate and its agents shall make available to CE, within
ten (10) business days of notice by CE, the information required to provide an accounting of
disclosures to enable CE to fulfill its obligations under the HIPAA Rules, including, but not
limited to, 45 C.F.R. Section 164.528. In the event that the request for an accounting is delivered
directly to Associate or its agents, Associate shall within five (5) business days of the receipt
of the request, forward it to CE in writing. It shall be CE's responsibility to prepare and deliver
any such accounting requested. Associate shall not disclose any Protected Information except
as set forth in Section 2(b) of this Agreement.
f. Governmental Access to Records. Associate shall keep records and make its
internal practices, books and records relating to the use and disclosure of Protected Information
available to the Secretary of the U.S. Department of Health and Human Services (the
"Secretary,) in a time and manner designated by the Secretary, for purposes of determining
CE's or Associate's compliance with the HIPAA Rules. Associate shall provide to CE a copy
of any Protected Information that Associate provides to the Secretary concurrently with
providing such Protected Information to the Secretary when the Secretary is investigating CE.
Associate small cooperate with the Secretary if the Secretary undertakes an investigation or
compliance review of Associate's policies, procedures or practices to determine whether
Associates complying with the HIPAA Rules, and permit access by the Secretary during
normal business hours to its facilities, books, records, accounts, and other sources of
information, including Protected Information, that are pertinent to ascertaining compliance.
g. Minimum Necessary. Associate (and its agents) shall only request, use, and
disclose the minimum amount of Protected Information necessary to accomplish the purpose of
the request. use, or disclosure, in accordance with the Minimum Necessary requirements of the
HIPAA Rules, including, but not limited to, 45 C.F.R. Sections 164.502(b) and 164.514(d).
h. Data Ownership. Associate acknowledges that Associate has no ownership
rights with respect to the Protected Information.
i. Retention of Protected Information. Except upon termination of all functions,
activities, cr services performed or provided by the Associate, Associate or agents shall retain
all Protected Information and shall continue to maintain the information for a period of six (6)
years.
j. Notification of Breach. During the term of this Agreement, Associate shall
notify CE within five (5) business days of any suspected or actual breach of security, intrusion
or unauthorized use or disclosure of Protected Information and/or any actual or suspected use
or disclosure of data in violation of any applicable federal or state laws or regulations. Associate
shall not initiate notification to affected individuals per the HIPAA Rules without prior
notification and approval of CE. Information provided to CE shall include the identification of
each individual whose unsecured PHI has been, or is reasonably believed to have been accessed,
acquired or disclosed during the breach. Associate shall take (i) prompt corrective action to cure
any such deficiencies and (ii) any action pertaining to such unauthorized disclosure required by
applicable federal and state laws and regulations.
k. Safeguards During Transmission. Associate shall be responsible for using
appropriate safeguards, including encryption of PHI, to maintain and ensure the confidentiality,
integrity and security of Protected Information transmitted to CE pursuant to the Agreement, in
accordance with the standards and requirements of the HIPAA Rules.
1. Restrictions and Confidential Communications. Associate will not respond
directly to an individual's requests to restrict the use or disclosure of Protected Information or
to send all communication of Protected Information to an alternate address. Associate will refer
such requests to the CE so that the CE can coordinate and prepare a timely response to the
requesting individual and provide direction to Associate.
4. Obligations of CE.
a. Safeguards During Transmission. CE shall be responsible for using appropriate
safeguards, including encryption of PHI, to maintain and ensure the confidentiality, integrity
and security of Protected Information transmitted pursuant to this Agreement, in accordance
with the standards and requirements of the HIPAA Rules.
b. Notice of Changes. CE maintains a copy of its Notice of Privacy Practices on its
website. CE shall provide Associate with any changes in, or revocation of, permission to use or
disclose Protected Information, to the extent that it may affect Associate's permitted or required
uses or disclosures. To the extent that it may affect Associate's permitted use or disclosure of
PHI, CE shall notify Associate of any restriction on the use or disclosure of Protected
Information that CE has agreed to in accordance with 45 C.F.R. Section 164.522.
5. Reasonable Steps to Cure Breach.
a. If CE knows of a pattern of activity or practice of Associate that constitutes a
material breach or violation of the Associate's obligations under the provisions of this
Agreement or another arrangement, then CE shall take reasonable steps to cure such breach or
end such violation. If Associate knows of a pattern of activity or practice of an agent that
constitutes a material breach or violation of agent's obligations under the written agreement
between Associate and the agent, Associate shall take reasonable steps to cure such breach or
end such violation, if feasible.
6. Disposition of the PHI upon Termination or Expiration.
a. Upon termination or expiration of any agreement for services between the
Parties, the Associate will either return or destroy, at CE's sole discretion and in accordance
with any instructions by CE, all PHI in the possession or control of the Associate and its agents.
However, if the Associate determines that neither the return nor destruction of the PHI is
feasible, the Associate may retain the PHI provided that the Associate complies with those
reasonable restrictions imposed by the CE.
7. Disclaimer. CE makes no warranty or representation that compliance by Associate with
this Agreement or the HIPAA Rules will be adequate or satisfactory for Associate's own
purposes. Associate is solely responsible for all decisions made by Associate regarding the
safeguarding of PHI.
8. Assistance in Litigation or Administrative Proceedings. Associate shall make itself and
any employees or agents assisting Associate in the performance of its obligations under the
Agreement, available to CE, at no cost to CE, up to a maximum of thirty (30) hours, to testify
as witnesses or otherwise, in the event of litigation or administrative proceedings being
commenced against CE, its directors, officers, or employees based upon a claimed violation of
the HIPAA Rules or other laws relating to security and privacy or PHI, in which the actions of
Associate are at issue, except where Associate or its employee or agent is a named adverse
party.
9. Interpretation and Order of Precedence. The provisions of this Agreement shall be
interpreted as broadly as necessary to implement and comply with the HIPAA Rules. The
parties agree that any ambiguity in this Agreement shall be resolved in favor of a meaning that
complies and is consistent with the HIPAA Rules.
10. Survival of Certain Agreement Terms. Notwithstanding anything herein to the contrary,
Associate's obligations under this Agreement shall survive termination of this Agreement and
shall be enforceable by CE as provided herein in the event of such failure to perform or comply
by the Associate.
11. Representatives and Notice. For the purpose of the Agreement, the individuals identified
on Page 1 of 4 Pages of this agreement shall be the representatives of the respective parties. All
required notices shall be hand delivered or given by certified or registered mail to the
representatives at the addresses listed at the top of this form.
Exhibit B
Scope of Services and Rates
1. Scope of Services
a. Services to be provided are detailed in the Individual's State Supported Living Services
(SLS) or OBRA Service Plan which dictates the type of service as well as timing and
frequency of service to be performed.
b. Approved VENDOR State SLS and OBRA services provided under this agreement:
❑ D2999: State SLS - Dental
❑ H1010: CES — Parent Education
❑ H2019: State SLS — Behavioral Consultation
❑ H2019: DD — Behavioral Counseling Individual
❑ H2019: SLS — Behavioral Counseling Individual
❑ H2019: OBRA — Counseling Individual
❑ H2019: State SLS — Counseling Services Individual
❑ H2021: State SLS - Mentorship
❑ H2023: State SLS — Supp Employment -Job Development
❑ S5130: SLS — Homemaker Basic
❑ S5130: State SLS — Homemaker Basic
❑ S5130: State SLS — Homemaker Enhanced
❑ S5150: State SLS — Respite Individual per 15 minutes
❑ S5151: State SLS — Respite Individual Per Day
❑ S5161: State SLS — Personal Emergency
❑ S5161: SLS — Personal Emergency Response Services
❑ S5165: CES — Home Accessibility Adaptations
❑ S5199: CES — Adapted Therapeutic Recreational Fees
❑ S8940: CES — Hippotherapy - Individual
❑ S8940: SLS — Hippotherapy - Individual
❑ T1019: State SLS - Personal Care
❑ T1999: CES — Adapted Therapeutic Recreational Equipment
❑ T2003: State SLS — Transportation Mileage
❑ T2003: State SLS — Transportation Mileage nonday
❑ T2003: SLS — Transportation Mileage Band 1
❑ T2004: State SLS — Transportation Other
❑ T2004: DD — Transportation — Other (Public Conveyance)
❑ T2004: SLS — Transportation — Other (Public Conveyance)
❑ T2019: State SLS - Supportive Employment Individual
❑ T2019: State SLS - Supportive Employment Group
❑ T2021: State SLS — Day Habilitation Supp Comm Connect
❑ T2021: State SLS — Day Habilitation Specialized Hab
❑ T2024: State — Behavioral Assessment
O T2028: DD — Specialized Medical Supplies — Disposable
Exhibit B
Scope of Services and Rates
❑ T2028: SLS — Specialized Medical Supplies - Disposable
❑ T2029: CES — Specialized Medical Equipment
❑ T2029: DD — Specialized Medical Equipment
❑ T2029: SLS — Specialized Medical Equipment
❑ T2035: CES — Assistive Technology
❑ V2799: DD — Vision Services
❑ V2799: SLS — Vision Services
❑ V2799: State SLS — Vision Services
❑ 97124: CES — Message Therapy
❑ 10000: State SLS — Acquiring Pest Abatement
2. Provider Rates and Fee Schedule
a. Rates paid for State SLS and OBRA services can be found on the State Health Care
Policy and Financing Website https://hcpf.colorado.gov/provider-rates-fee-schedule, see
State General Fund Programs Direct Service Rates Fee Schedule.
Terms
1. Home and Community Based Service (HCBS) Provider Agency Billing
a. Claims for HCBS services are payable only if submitted in accordance with the
following procedures:
i. VENDOR shall verify Member eligibility prior to delivering services;
ii. VENDOR shall verify a Prior Authorization Request (PAR) has been
approved for the services in question, prior to service provision and claim
submission;
iii. Claims shall be submitted to the Fiscal Agent in accordance with
Department billing manuals and policies, outlined in 10 C.C.R. 2505-10
Section 8.043;
iv. Claims shall only be submitted for services the VENDOR is enrolled to
provide, including correct HCBS specialties;
v. Claims shall only be submitted for services provided in accordance with
all applicable federal and state statutes, regulations, and other authorities;
vi. Submitted claims shall include all data elements required to complete the
National Uniform Claim Committee Form 1500 (CMS 1500).
b. Payment shall not exceed rate shown in the Health First Colorado Fee Schedule in
effect on the date services are provided.
c Pursuant to § 25.5-4-301, C.R.S., VENDOR shall not collect copayments or seek
reimbursement from eligible Members for covered services.
2. Personnel
a. Employee and Contractor records
i. The VENDOR shall maintain records documenting the qualifications and
Exhibit B
Scope of Services and Rates
training of employees and Contractors who provide services to Members.
ii. The VENDOR shall maintain a personnel record for each employee or
Contractor. The record shall contain:
• Documentation of employee/Contractor qualifications.
■ Documentation of trainings completed.
• Documentation of supervision and performance evaluation or contractor
management.
Documentation that the employee/Contractor was informed of all policies
and procedures required by Section 8.7409.
Documentation of the employee's/Contractor's job description.
Documentation of a criminal background check and a CAPs check.
3. License/Certification
a. The VENDOR shall meet the enrollment requirements for each service it provides
prior to providing services. The VENDOR shall ensure each employee or
independent Contractor maintains the necessary and appropriate license and/or
Certification to render services. The VENDOR shall maintain documentation of
current and valid individual license(s) and Certification(s) in the personnel record.
4. Medication Administration
a. All employees and Contractors, not otherwise authorized by law to administer
medication, who assist and/or monitor Members in the administration of
medications or the filling of medication reminder boxes shall have passed a
"Qualified medication administration person" or "QMAP" competency evaluation
offered by an approved training entity, and shall be listed on the Department's list
of persons who have passed the requisite competency evaluation as defined in 6
CCR 1011-1, Chapter 24. Each facility shall ensure the qualifications of the
QMAP employee or Contractor per 6 CCR 1011-1, Chapter 24, Section 3.
5. Trainings
a. The VENDOR shall have an organized program of orientation and training of
sufficient scope for employees and Contractors to carry out their duties and
responsibilities efficiently, effectively, and competently. Training shall be
provided prior to employees or Contractors having unsupervised contact with
Members. The training program shall, at a minimum, provide for and include:
i. Training related to person -centered practices, the role of the Person -Centered
Support Plan, and the concept of dignity of risk;
ii. Training related to health, safety, and services and supports to be provided
related to the specific needs and diagnoses of Members served;
iii. Training specific to the individual(s) for whom the employees or Contractors
will be providing services and supports which includes medical or behavioral
protocols, supervision, dietary and Activities of Daily Living (ADL) needs,
and Provider agencies' internal policies and procedures.
6. Rendering Services According to the Person -Centered Support Plan
Exhibit B
Scope of Services and Rates
a_ The VENDOR shall maintain, on file, copies of the current Person -Centered
Support Plan for all Members they serve. Staff providing direct care to Members
shall have access to or a copy of the support plan Person -Centered Support Plan
and shall render services as required in the support plan Person -Centered Support
Plan.
b. The VENDOR shall render services according to the agreed upon Person -
Centered Support Plan and coordinate with other provider agencies, when
applicable. Members receiving services shall be included in developing the
Person -Centered Support Plan and have the freedom to choose a willing service
vendor.
c. The VENDOR shall not condition a Member's receipt of any service on the
Member's agreement to receive other services from the service vendor.
d The VENDOR shall not discontinue or refuse to provide agreed upon services to a
Member unless documented efforts have been made to resolve the situation that
triggers such discontinuation or refusal to provide services.
7. Incident Reporting
a. The VENDOR shall complete the timely reporting, recording, and reviewing of
Incidents which shall include, but not be limited to:
• Death of Member receiving services;
Hospitalization of Member receiving services;
Medical emergencies, above and beyond first aid, involving Member
receiving services;
• Allegations of MANE;
• Injury to Member or illness of Member;
• Damage or theft of Member's personal property;
• Errors in medication administration;
• Lost or missing person receiving services;
• Criminal activity; and
■ Incidents or reports of actions by Member receiving services that are
unusual and require review.
It The VENDOR shall submit a verbal or written report of every Incident to the
HCBS Member's Case Management Agency Case Manager within 24 hours of
discovery of the actual or alleged Incident. The report shall include:
• Name of person reporting;
• Name of Member who was involved in the Incident;
• Member's Medicaid identification number;
• Name of persons involved or witnessing the Incident;
• Incident type;
• Date, time, and duration of Incident;
• Location of Incident;
• Persons involved;
Exhibit B
Scope of Services and Rates
• Description of Incident;
• Description of action taken;
• Whether the Incident was observed directly or reported to the provider;
• Name of person notified;
• Follow-up action taken or where to find documentation of further
follow-up;
Name of the person responsible for follow up; and
Resolution, if applicable.
c. If any of the above information is not available and reported to the Case
Management Agency Case Manager within 24 hours of the Incident, the
VENDOR must submit follow up information as soon as it is obtained.
d. Additional follow up information may also be requested by the Case Manager, or
the Department. The VENDOR is required to submit all follow up information
within the timeframe specified by the Case Management Agency.
e. VENDOR shall review and analyze information from Incident reports to identify
trends and problematic practices which may be occurring in specific services and
shall take appropriate corrective action to address problematic practices identified.
1
Vendor
Alternatives' Access, LLC
Service
Code
Service Description
H2021
State SLS - Mentorship
S5130
State SLS - Homemaker Enhanced
T1019
State SLS - Personal Care
T2003
State SLS - Transportation Mileage
T2003
State SLS - Transportation mileage non day
T2019
State SLS - Supportive Employment Individual
T2021
State SLS - Day Habilitation Supp Comm Connec
2
Andrea's Angels
S5130
State SLS - Homemaker Enhanced
3
Banner Home Care
S5161
State SLS-Personal Emergency
4
Behavior Services of the Rockies
H2019
State SLS-Behavioral Consultation
H2019
State SLS - Counseling Services Individual
T2024
State -Behavioral Assessment
5
City of Greeley
T2004
State SLS - Transportation Other
6
Dragonfly Support Services
S5130
State SLS - Homemaker Basic
T2003
State SLS - Transportation Mileage
T2021
State SLS - Day Habilitation Supp Comm Connec
7
Durable Life Skills, Inc.
S5130
State SLS - Homemaker Enhanced
8
Easter Seals Of Colorado Springs
H2023
State SLS - Supp Employment -Job Development
T2019
State SLS - Supportive Employment Individual
9
Effective Pest Services
10000
State SLS- Acquiring Pest Abatement
10
Eyemart Express
V2799
State SLS - Vision Services
11
Imagine!
S5150
State SLS - Respite Individual per 15 minutes
T2021
State SLS - Day Habilitation Supp Comm Connec
12
Integrated Life Choices
H2021
State SLS - Mentorship
S5130
State SLS - Homemaker Enhanced
S5130
State SLS - Homemaker Basic
T1019
State SLS - Personal Care
T2003
State SLS - Transportation Mileage
T2003
State SLS - Transportation mileage non day
T2021
State SLS - Day Habilitation Supp Comm Connec
T2021
State SLS - Day Habilitation Specialized Flab
13
My Eye Dr.
V2799
State SLS - Vision Services
14
Northern Colorado Periodontics
D2999
State SLS - Dental
15
Otero Corporation
Vendor
Service
Code
T2003
Service Description
State SLS - Transportation Mileage
T2021
State SLS - Day Habilitation Supp Comm Connec
16
Overture/Carmel
T2003
State SLS - Transportation Mileage
T2003
SLS - Transportation - Mileage Band 1
T2021
State SLS - Day Habilitation Supp Comm Connec
T2021
State SLS - Day Habilitation Specialized Hab
17
Parkview Dental Care
D2999
State SLS - Dental
18
Perklen Center for Psychotherapy
H2019
State SLS - Counseling Services Individual
H2019
SLS - Behavioral Counseling Individual
19
Precious Hands Ccnmunity Helpers
H2021
State SLS - Mentorship
S5130
State SLS - Homemaker Enhanced
S5130
State SLS - Homemaker Basic
S5130
SLS - Homemaker Basic
T1019
State SLS - Personal Care
20
Program Services -Supported Living Services
T2003
State SLS - Transportation Mileage
T2019
State SLS - Supportive Employment Individual
T2021
State SLS - Day Habilitation Specialized Hab
T2021
State SLS - Day Habilitation Supp Comm Connec
21
Rural Alternative for Transportation
T2004
State SLS - Transportation Other
22
Schaefer Enterprises, Inc
T2003
State SLS - Transportation Mileage
T2019
State SLS - Supportive Employment Group
T2019
State SLS - Supportive Employment Individual
T2021
State SLS - Day Habilitation Supp Comm Connec
23
Schweers, David
H2019
State SLS - Counseling Services Individual
24
Special Kids Special Families
S5150
State SLS - Respite Individual per 15 minutes
S5151
State SLS - Respite Individual Per Day
25
Tippets Dentistry
D2999
State SLS - Dental
26
Unique Services ofP orthern CO
H2021
State SLS - Mentorship
T2019
State SLS - Supportive Employment Individual
27
Wonder Years
T2019
State SLS - Supportive Employment Individual
Hello