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HomeMy WebLinkAboutC06-284DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT DEPARTMENT OR AGENCY NUMBER FLA CONTRACT ROUTING NUMBER 07 -00350 TASK ORDER PSD -MCH This Task Order is made this 6TH day of SEPTEMBER, 2006, by and between: the state of Colorado, acting by and through the COLORADO 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, the (BOARD OF COUNTY COMMISSIONERS OF EAGLE COUNTY (a political subdivision of the state of Colorado), whose address or principal place of business is 500 Broadway Eagle Colorado 81631, for the use and benefit of the Eagle County Health & Human Services whose address or principal place of business is 551 Broadway, Eagle, Colorado 81631, hereinafter referred to as "the Contractor ". FACTUAL RECITALS Pursuant to section 25-1.5-1010) (I), C.R.S., as amended, the General Assembly of the state of Colorado has declared that the state "has, in addition to all other powers and duties imposed upon it by law, the powers and duties to disseminate public health information." Section 25 -1.5 -101 (r), C.R.S., as amended, states that the state can, "operate and maintain a program for children with disabilities to provide and expedite provision of health care services to children who have congenital birth defects or who are the victims of burns or trauma or children who have acquired disabilities ". To accomplish its statutory duties, the State has determined that public health services are desirable in the Contractor's region. The United State Department of Health and Human Services ( "HHS "), through the Maternal and Child Health Services Block Grant (MCH) has awarded the State Title V federal funds under Notice of Grant Award ( "NGA) number B04MC04248 (See, Catalog of Federal Domestic Assistance ( "CFDA ") number 93.994). The State's Prevention Services Division (PSD) is charged with the administration of funds from the Title V MCH Block Grant to improve the health and well being of the maternal and child /adolescent populations through assessing population needs, influencing health policy, engaging in strategic planning and coordinating/implementing best practices and evidenced -based programs. The authority for the administration of the Title V MCH Block Grant, including the maternal, child and children with special health care needs resides in Title V of the Social Security Act, §§ 501 -509. Each state that receives MCH funds from the HHS must demonstrate to the HHS that it has served three (3) distinct population groups with the MCH funds. These three (3) distinct population groups are: "the perinatal population ", which is defined to include women of childbearing age, pregnant women, and mothers; the "child and youth population ", which is defined to include infants, children, and adolescents from birth through age twenty (20); and, the "children with special health care needs population" (CSHCN), which is defined as those children who have, or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. Page 1 of 10 A The State has formulated a comprehensive statewide plan to carry out a Maternal and Child Health Program, funded by Title V MCH dollars. As part of the comprehensive plan, it is the express intent of the state to support local public health agencies in contributing to a coordinated, efficient statewide program, which focuses on specific MCH performance measures set by the MCH State and Federal agencies. Local public health agencies, working in partnership with other community organizations, facilitate the development and enhancement of community-based systems of care for the maternal and child population. The goal of these systems is to ensure that all families have access to direct care services, as well as, enabling and population -based services that address the issues and health problems delineated in the MCH performance measures. Section 29 -1 -201, C.R.S. as amended, encourages governments to make the most efficient and effective use of their powers and responsibilities by cooperating and contracting with each other to the fullest extent possible to provide any function, service, or facility lawfully authorized to each of the cooperating or contracting entities. Section 29 -1- 201, C.R.S., as amended, further states that all state of Colorado contracts with its political subdivisions are exempt from the state of Colorado's personnel rules and procurement code. The Contractor is a political subdivision of the state of Colorado. The State and the Contractor mutually agree that the most efficient and effective way to provide the above - described services is at the local level. The State and the Contractor previously entered into a Master Contract with contract routing number 05 FAA 00132. This Task Order is issued pursuant to the terms and conditions of that Master Contract. As to the State, authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment in Fund Code(s) 100, Organizational Unit Code 6520, Appropriation Code 581, Program Code(s) 9017, Function Code(s) FLWT, Object Code(s) 5120, and Grant Budget Line Codes) MC7A and MC7B for the Prenatal and Child /Adolescent services; Fund Code(s) 100, Organizational Unit Code 6810, Appropriation Code 606, 611, and 665, Program Code(s) 9017, Function Code(s) FLWT, Object Code(s) 5120, and Grant Budget Line Code(s) MC7* and MC7C for the Health Care Program for Children with Special Needs (HCP); and Fund Code(s) 100, Organizational Unit Code 6810, Appropriation Code 665, Program Code(s) 9017, Function Code(s) FLWT, Object Code(s) 5120, and Grant Budget Line Code(s) JX6G for the State Genetics Implementation Grant services under Contract encumbrance number PO FLA MCH0700350. And, authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment in Fund Code(s) 100, Organizational Unit Code(s) 6810, Appropriation Code(s) 609, Program Code(s) 9017, Function Code(s) FLWT, Object Code 5120, and Grant Budget Line Code(s) OF6P under Contract encumbrance number PO FLA HCP07000001 for Traumatic Brain Injury (TBI) Services. All required approvals, clearances, and coordination have been accomplished from and with all appropriate agencies. Page 2 of 10 NOW, THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: A. PERIOD OF PERFORMANCE AND TERMINATION. The proposed effective date of this Task Order is October 1, 2006. However, in accordance with section 24 -30- 202(1), C.R.S., as amended, this Task Order is not valid until it has been approved by the State Controller, or an authorized designee thereof. The Contractor is not authorized to, and shall not, commence performance under this Task Order until this Task Order has been approved by the State Controller. 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. If the State Controller approves this Task Order on or before its proposed effective date, then the Contractor shall commence performance under this Task Order on the proposed effective date. If the State Controller approves this Task Order after its proposed effective date, then the Contractor shall only commence performance under this Task Order on that later date. The initial term of this Task Order shall commence on the effective date of this Task Order and continue through and including September 30, 2007, unless sooner terminated by the parties pursuant to the terms and conditions of this Task Order. In accordance with section 24- 103 -503, C.R.S., as amended, and Colorado Procurement Rule R -24 -103 -503, the total term of this Contract, including any renewals or extensions hereof, may not exceed five (5) years. B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order, shall perform and complete, in a timely and satisfactory manner, all work items described in the Statement of Work, which are incorporated herein by this reference, made a part hereof and attached hereto as "Exhibit A ". The State and the Contractor have determined that the Contractor is a business associate under HIPAA in regards to the TBI services in this Task Order. Contractor hereby agrees to, and has an affirmative duty to, execute the State's current HIPAA Business Associate Agreement, which is attached hereto as "Exhibit B ", and incorporated herein by this reference. This Business Associate Agreement shall be fully and properly executed by the Contractor and returned to the State at the time the Contractor signs the primary task order of which this exhibit is a part. C. DUTIES AND OBLIGATIONS OF THE STATE. In consideration of those HCP services satisfactorily and timely performed by the Contractor under this Task Order, the State shall cause to be paid to the Contractor a sum not to exceed THIRTEEN THOUSAND SIX HUNDRED TWENTY -TWO DOLLARS ($13,622.00) for the initial term of this Task Order. Of the HCP financial obligation, Six Thousand One Hundred Thirty Dollars, ($6,130.00) are identified as attributable to a funding source of the United States government and, Seven Thousand Four Hundred Ninety -Two Dollars ($7,492.00) are identified as attributable to a funding source of the state of Colorado. In consideration of those State Genetics Implementation Grant services satisfactorily and timely performed by the Contractor under this Task Order, the State shall cause to be paid to the Contractor a sum not to exceed TWO THOUSAND EIGHT HUNDRED FIFTY -EIGHT DOLLARS, ($2,858.00) for the initial term of this Task Order. Of the State Genetics Implementation Grant financial obligation, Two Thousand EiJjht Hundred Fifty -EiLlht Dollars ($2,858.00) are identified as attributable to a funding source of the United States government and, Zero Dollars, ($0.00) are identified as attributable to a funding source of the state of Colorado. Page 3 of 10 I In consideration of those Prenatal and Child /Adolescent services satisfactorily and timely performed by the Contractor under this Task Order, the State shall cause to be paid to the Contractor a sum not to exceed THREE THOUSAND TWO HUNDRED FORTY -EIGHT DOLLARS, ($3,248.00) for the initial term of this Task Order. Of the Prenatal and Child/Adolescent financial obligation, Three Thousand Two Hundred Forty -Eight Dollars, ($1248.00) are identified as attributable to a funding source of the United States government and, Zero Dollars, ($0.00) are identified as attributable to a funding source of the state of Colorado. 4. Of the total combined HCP, State Genetics Implementation Grant, and Prenatal and Child /Adolescent financial obligation referenced in paragraphs C. 1., C. 2., and C. 3. above, of NINETEEN THOUSAND SEVEN HUNDRED TWENTY -EIGHT DOLLARS, ($19,728.00)for the initial term of this Task Order, Twelve Thousand Two Hundred Thirty -Six Dollars, ($12,236.00) are identified as attributable to a funding source of the United States government and, Seven Thousand Four Hundred Ninety -Two Dollars, ($7,492.00) are identified as attributable to a funding source of the state of Colorado. Payments under this Task Order shall be a combined monthly payment with a portion of each payment from the HCP, State Genetics Implementation Grant, and Prenatal and Child /Adolescent funds and are subject to verification by the State that the Contractor has fully and satisfactorily complied with the terms and conditions of this Task Order. Monthly reimbursements under this Task Order for the period of October 1, 2006 through September 30, 2007 shall be paid to the Contractor by the State based upon one - twelfth (1/12) of the total financial obligation referenced above in paragraphs C. 1., C. 2., and C.3. or ONE THOUSAND SIX HUNDRED FORTY - FOUR DOLLARS, ($1,644.00) for each of the twelve (12) months of the initial term of this Task Order. The total cumulative reimbursements may not exceed the total financial obligation of the State referenced above in paragraph C. 4. for this Task Order period. In addition to the budget referenced in paragraphs C. 1., C. 2., and C. 3. above, the Contractor shall be reimbursed for the initial term of this Task Order, for TBI services for a sum not to exceed Nine Hundred Dollars ($900.00) per child for twelve (12) months of services. Upon receipt of a TBI Care Coordination Invoice, incorporated herein by this reference, made a part hereof, and attached hereto as "Exhibit C ", payments shall be made in twelve (12) monthly increments as follows: $240 for the month in which the family signs the Care Coordination Plan and $60 for each of the eleven succeeding months, as long as the client is in active status. Contractor shall only be reimbursed for months for which the client's status in the HCP /Clinical Health Information Record of Patients (CHIRP) database is "Active." Payment pursuant to this Contract shall be made as earned, in whole or in part, from available funds encumbered in an amount not to exceed ONE HUNDRED NINE THOUSAND, EIGHT HUNDRED DOLLARS ($109,800.00) Statewide for TBI services for federal fiscal year 2006- 2007 (October 1, 2006 through and including September 30, 2007). Of this total financial obligation, ZERO DOLLARS, ($0.00) are identified as attributable to a funding source of the federal government and, ONE HUNDRED NINE THOUSAND, EIGHT HUNDRED DOLLARS ($109,800.00) are identified as attributable to a funding source of the state of Colorado. The liability of the State, at any time, for such payments shall be limited to the unencumbered remaining balance of such funds. If there is a reduction in the total funds appropriated for the purposes of this Contract, then the State, in its sole discretion, may proportionately reduce the funding for this Contract or terminate this Contract in its entirety. Payments under this Task Order shall be made through the State's Electronic Fund Transfer system. Page 4of10 The State may prospectively increase or decrease the amount payable under this Task Order through a "Task Order Change Order Letter" that is substantially similar to the sample Task Order Change Order Letter that is incorporated herein by this reference, made a part hereof, and attached hereto as "Exhibit D ". To be effective, a Task Order Change Order Letter must be: signed by the State and the Contractor; and, approved by the State Controller or an authorized designee thereof. Additionally, a Task Order Change Order Letter shall include the following information: A. Identification of the related Master Contract and this Task Order by their respective contract routing numbers and affected paragraph number(s); B. The type(s) of service(s) or program(s) increased or decreased and the new level of each service or program; C. The amount of the increase or decrease in the level of funding for each service or program and the new total financial obligation; D. A provision stating that the Task Order Change Order Letter is effective upon approval by the State Controller, or designee, or its proposed effective date, whichever is later. Upon proper execution and approval, a Task Order Change Order Letter shall become an amendment to this Task Order. Except for the General and Special Provisions of the Master Contract, and the Additional Provisions of the Task Order, if any, the Task Order Change Order Letter shall supersede this Task Order in the event of a conflict between the two. It is expressly understood and agreed to by the parties that the task order change order letter process may be used only for increased or decreased levels of funding, corresponding adjustments to service or program levels, and any related budget line items. Any other changes to this Task Order, other than those authorized by the task order option to renew letter process described below, shall be made by a formal amendment to this Task Order executed in accordance with the Fiscal Rules of the state of Colorado. If the Contractor agrees to and accepts a proposed Task Order Change Order Letter, then the Contractor shall execute and return that Task Order Change Order Letter to the State by the date indicated in that Task Order Change Order Letter. If the Contractor does not agree to and accept a proposed Task Order Change Order Letter, or fails to timely return a partially executed Task Order Change Order Letter by the date indicated in that Task Order Change Order Letter, then the State may, upon written notice to the Contractor, terminate this Task Order no sooner than thirty (30) calendar days after the return date indicated in the Task Order Change Order Letter has passed. This written notice shall specify the effective date of termination of that Task Order. If a Task Order is terminated under this clause, then the parties shall not be relieved of their respective duties and obligations under that Task Order until the effective date of termination has passed. Increases or decreases in the level of contractual funding made through the task order change order letter process during the initial, or renewal, term of a Task Order -may only be made under the following circumstances: E. If necessary to fully utilize appropriations of the state of Colorado and /or non - appropriated federal grant awards; F. Adjustments to reflect current year expenditures; G. Supplemental appropriations, or non - appropriated federal funding changes resulting in an increase or decrease in the amounts originally budgeted and available for the purposes of a Task Order; H. Closure of programs and/or termination of related contracts or task orders; Page 5 of 10 Delay or difficulty in implementing new programs or services; and, Other special circumstances as deemed appropriate by the State. The State may renew a Task Order through a "Task Order Option to Renew Letter" substantially similar to the sample Task Order Option to Renew Letter that is incorporated herein by this reference, made a part hereof, and attached hereto as "Exhibit E ". To be effective, a Task Order Option to Renew Letter must be: signed by the State and the Contractor; and, approved by the State Controller or an authorized designee thereof. Additionally, a Task Order Option to Renew Letter shall include the following information: A. identification of the related Master Contract and that Task Order by their respective contract routing numbers and affected paragraph number(s); B. The type(s) of service(s) or program(s), if any, increased or decreased and the new level of each service or program for the renewal term; C. The amount of the increase or decrease, if any, in the level of funding for each service or program and the new total financial obligation; D. A provision stating that the Task Order Option to Renew Letter is effective upon approval by the State Controller, or designee, or its proposed effective date, whichever is later. Upon proper execution and approval, a Task Order Option to Renew Letter shall become an amendment to this Task Order. Except for the General and Special Provisions of the Master Contract, and the Additional Provisions, if any of that Task Order, a Task Order Option to Renew Letter shall supersede that Task Order in the event of a conflict between the two. It is expressly understood and agreed to by the parties that the task order option to renew letter process may be used only to: renew a Task Order; increase or decrease levels of funding related to that renewal; make corresponding adjustments to service or program levels, and, adjust any related budget line items. Any other changes to a Task Order, other than those authorized by the task order change order letter process described above, shall be made by a formal amendment to a Task Order executed in accordance with the Fiscal Rules of the state of Colorado. If the Contractor agrees to and accepts a proposed Task Order Option to Renew Letter, then the Contractor shall execute and return that Task Order Option to Renew Letter to the State by the date indicated in that Task Order Option to Renew Letter. If the Contractor does not agree to and accept the proposed renewal term, or fails to timely return a partially executed Task Order Option to Renew Letter by the date indicated in that Task Order Option to Renew Letter, then the State may, upon written notice to the Contractor, terminate this Task Order no sooner than thirty (30) calendar days after the return date indicated in the Task Order Option to Renew Letter has passed. This written notice shall specify the effective date of termination of that Task Order. If a Task Order is terminated under this clause, then the parties shall not be relieved of their respective duties and obligations under that Task Order until the effective date of termination has passed. 10. All attachments or exhibits to this Task Order are incorporated herein by this reference and made a part hereof as if fully set forth herein. If a conflict or inconsistency is found to exist between the terms and conditions of this Task Order and those of any attachment or exhibit hereto, then the terms and conditions of this Task Order shall control. Page 6 of 10 D. ADDITIONAL PROVISIONS 1. Contractor is encouraged to attend regional teleconferences, meetings, and /or videoconference meetings, as appropriate, that the state may organize to address priority Prenatal and Child /Adolescent and /or HCP needs, promote learning groups, increase skills as Prenatal and Child /Adolescent and /or HCP practitioners and /or carry out state and local MCH planning activities. 2. Contractor shall cooperate with the State and provide all requested records regarding recipients for whom services were provided under this Task Order. 3. The Contractor shall cooperate with the State to ensure that the program planning, evaluation, and monitoring requirements as described in this Task Order and the Attachments are met. This cooperation includes, but is not limited to participation in mutually agreed upon site visits at the Contractor's location. 4. Contractor shall retain and use all revenues generated by the individual MCH Programs for services in those programs. 5. The State is responsible to ensure that the program planning, evaluation, and monitoring requirements as described in this Task Order and the Attachments are met by the Contractor. To fulfill these responsibilities, the State has the right to make site visits and schedule any other meetings at the Contractor's location. 6. The State HCP Office shall assure the HCP Regional Office provides technical assistance and that the technical assistance is coordinated with the Public Health Nursing Consultant in the State's Office of Local Liaison. 7. Title V, Section 504 (b) (6). Title V funds may not be used to pay for any item or service (other than an emergency item or service) furnished by an individual or entity convicted of a criminal offense under the Medicare or any State health care program (i.e., Medicaid, Maternal and Child Health, or Social Services Block Grant Programs). 8. The Contractor agrees to provide services to all Program participants and employees in a smoke -free environment in accordance with Public Law 103 -227, also known as "the Pro - Children Act of 1994 ", (Act). Public Law 103 -227 requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable Federal funds is Medicare or Medicaid; or facilities where WIC coupons are redeemed. Failure to comply with the provision of Public Law 103 -227 may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and /or the imposition of an administrative compliance order on the responsible entity. By signing this Task Order, the Contractor certifies that the Contractor will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. The Contractor agrees that it will require that the language of the Act be included in any subcontracts which contain provisions for children's services and that all contractors shall sign and agree accordingly. Page 7 of 10 9. The Contractor certifies, to the best of its knowledge and belief, that no federally appropriated funds have been paid or will be paid by or on behalf of the Contractor, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of this Task Order, and the extension, continuation, renewal, amendment, or modification of this Task Order, or any grant, loan, or other cooperative agreement that utilizes Federal funds. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, Member of Congress, an officer or employee of Congress in connection with this Task Order, or any other grant, loan, or other cooperative agreement, then the Contractor shall complete and submit Standard Form - LLL, "Disclosure Form to Report Lobbying" in accordance with its instructions. The Contractor shall require that the language of this certification be included in the award documents for subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. This certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. 10. The Contractor shall not charge for services those individuals of families at or below the official poverty guidelines, updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2), in accordance with Title V, Section 501 (1) (B) and Section 505 (5) (D). The 100 percent of poverty gross income guideline for farm or non -farm families is currently at $9,800 for a family of 1, $13,200 for a family of 2; $16,600 for a family of 3; $20,000 for a family of 4; $23,400 for a family of 5; $26,800 for a family of 6; $30,200 for a family of 7; and $33,600 for a family of 8. For families of more than eight, add $3,400 for each additional member. If any charges are imposed for services to clients who are above the 100% of poverty level, such charges must be on a sliding scale which takes into account the client's family size, income and resources. These charges and the sliding fee scale must be made available to the general public and to all clients and must be based on the agency's usual and customary cost for the service. Clients must understand they will not be denied services for inability to pay any of the sliding fee charges. 11. The Contractor shall protect the confidentiality of all applicant or recipient records and other materials that are maintained in accordance with this Task Order. Except for purposes directly connected with the administration of this Task Order, no information about or obtained from, any applicant or recipient shall be disclosed in a form identifiable with the applicant or recipient without the prior written consent of the applicant or recipient, or the parent or legal guardian of a minor applicant or recipient with the exception of information protected by Colorado statute as it applies to confidentiality for adolescent services in which case the adolescent minor and not the parent or legal guardian must provide consent or, as otherwise properly ordered by a court of competent jurisdiction. The Contractor shall have written policies governing the access to, and duplication and dissemination of, all such information. The Contractor shall advise its employees, agents, servants, and subcontractors, if any, that they are subject to these confidentiality requirements. Page 8of10 12. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of 1964 are carried out. That Act states that "no person in the United States shall on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." The Office of Civil Rights has concluded that it is the responsibility of any program which is a recipient of funds from the Department of Health and Human Services to ensure that clients who do not speak or understand English well, be provided interpretation services to ensure that the service provider and the client can communicate effectively. The Contractor shall have policies and procedures to ensure that interpretation services are available for clients with Limited English Proficiency and will advise such clients that an interpreter will be provided for them. If a client has their own interpreter, they shall be advised that the Contractor will provide an interpreter if the client so chooses. 13. The services or activities under this Task Order may be carried out by the Contractor itself, or through subcontracts with other providers or, through collaborative partnerships with other community partners. The State authorizes the Contractor to subcontract some, or all, of the services that are to be performed under this Task Order. However, a subcontractor is subject to all of the terms and conditions of this Task Order. Additionally, the Contractor remains ultimately responsible for the timely and satisfactory completion of all work performed by any subcontractor(s) under this Task Order. If the Contractor desires to subcontract some, or all, of the services that are to be performed under this Task Order, the Contractor shall obtain the prior, express, written consent of the State before entering into any subcontract. Page 9of10 IN WITNESS WHEREOF, the parties hereto have executed this Task Order as of the day first above written. CONTRACTOR: STATE: BOARD OF COUNTY COMMISSIONERS OF STATE OF COLORADO EAGLE COUNTY Bill Owens, Governor (a political subdivision of the state of Colorado) for the use and benefit of the Eagle County Nursing Service B � �' � l Y: By: Name: 0 For the Executive Director Title: Chair 6 DEPARTMENT OF PUBLIC HEALTH FEIN: 84- 6000762 AND ENVIRONMENT Date: Date: (Seal) ATTEST: PROGRAM APPROVAL: Iv Y By: City, City and Could ty, County, Special District, or Town Clerk or Equivalent APPROVALS: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24 -30 -202 requires that the State Controller approve all state contracts. This contract is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated to pay for the goods and /or services provided. Revised: 11/5/04 STATE CONTROLLER: Leslie M. Shenefelt By: Date: Page 10 of 10 EXHIBIT A STATEMENT OF WORK To Task Order Dated 09/06/2006 - Contract Routing Number 07 FLA 00350 This Statement of Work is for the three maternal and child health (MCH) populations, which cover prenatal, child /adolescent, and children and youth with special health care needs. Because there are some tasks pertaining to all three MCH populations, some tasks pertaining only to the prenatal and child /adolescent populations and other tasks pertaining only to the children and youth with special health care needs population this Statement of Work has been set up in three Sections; A. Maternal and Child Health (MCH), B. Prenatal and Child /Adolescent, and C. Health Care Program for Children with Special Needs (HCP). It is important to note that when the Contractor is requested to submit a report in an item in Section A the information provided is to be for all three MCH populations. A. Maternal and Child Health (MCH) Under this Task Order, a local public health agency, such as the Contractor shall provide the core public health services on behalf of the prenatal population, the child and adolescent population, and the children with special health care needs as described and defined in "Attachment A -1", "Core Public Health Services Delivered by MCH Agencies ", which is incorporated herein by this reference, made a part hereof, and attached hereto. Submission of Actual Budget Allocations for Federal Fiscal Year 2005-2006. On or before December 1, 2006, the Contractor shall submit to the State one (1) "Core Public Health Application and /or Expenditure Report" form showing the Contractor's actual budget allocations for the three (3) maternal and child populations, i.e., prenatal, child and adolescent, and children and youth with special health care needs (CYSHCN), for the federal fiscal year 2005 -2006 (October 1, 2005, through September 30, 2006). A sample form, which the Contractor shall utilize, is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment A -2. The completed report shall be submitted via electronic mail to: cdphe .psmchreports(i�state.co.us Submission of Numbers Served Report for Federal Fiscal Year 2005 -2006. On or before January 15, 2007, the Contractor shall submit to the State, for review and approval, a completed "Number of Individuals Served (Unduplicated) Under Title V Report", for those services provided by the Contractor in federal fiscal year 2005 -2006 (October 1, 2005, through September 30, 2006). A sample form, which the Contractor shall utilize, is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment A -3. This report shall be submitted via electronic mail to: Karen Trierweiler at: karen.trierweiler6ii,)state.co.us B. Prenatal and Child /Adolescent The Contractor shall provide leadership, in coordination with public and private community partners to: Contribute to the accomplishment of the State's priorities, performance measures, and outcome measures, as identified in "Attachment A -4 ", which is incorporated herein by this reference, made a part hereof, and attached hereto; Pagel of 5 rn 2. Plan for the development and maintenance of resources that assure access to direct care and services for vulnerable women, children, and adolescents, such as those who are low- income, uninsured, underinsured, or who live in rural or underserved areas or who are from ethnic or cultural minority communities and may experience language or cultural barriers to services; 3. Facilitate outreach and enrollment efforts, including having information and applications on site, to increase enrollment of eligible children and adolescents, including those with special health care needs, in Medicaid or Child Health Plan Plus+ (CHP +); and 4. Refer families participating in any and all programs in its agency such as WIC, EPSDT, Immunization Clinics, Family Planning, HCP, etc. to appropriate enabling and direct care service programs in the community. All pregnant women in need of resources for prenatal medical care shall be provided with information about programs such as Prenatal Plus, WIC, etc., as needed. The Contractor shall provide all individuals seeking reproductive health services: with information about pregnancy planning, the consequences of unintended pregnancies, and, referrals to comprehensive family planning services. 5. Include the maternal and child health population in the five -year community health assessment written for the State's Office of Local Liaison. 6. Include one or more MCH objectives in the "Annual Community Health Plan ", submitted to the State's Office of Local Liaison. B. Health Care Program for Children with Special Needs (HCP) I. The Contractor shall provide leadership, in coordination with public and private community partners to: a. Provide for the continuation of the core public health services of assessment, policy development, and assurance on behalf of the children and youth with special health care needs population and in implementing the 10 essential services for this population in partnership with the State, as identified in "Attachment A -5 ", which is incorporated herein by this reference, made a part hereof, and attached hereto; b. Plan for the development and maintenance of resources that assure access to direct care and services for vulnerable children and youth with special health care needs, such as those who are low- income, uninsured, underinsured, or who live in rural or underserved areas or who are from ethnic or cultural minority communities and may experience language or cultural barriers to services; C. Facilitate outreach and enrollment efforts, including having information and /or applications on site, to increase enrollment of eligible children and youth with special health care needs, in Medicaid, Colorado Child Health Plan Plus+ (CHP +), or Supplemental Security Income (SSI); and d. Plan for the development and implementation of population -based approaches for addressing MCH performance measures and priority issues for children and youth with special health care needs in the community. Page 2 of 5 The Contractor shall contribute to the Western Slope HCP Regional Office's Plan for CYSHCN, which shall be carried out in federal fiscal year 07. The Western Slope HCP Regional Office Plan is designed to: contribute to the accomplishment of the Maternal Child Health Six Core Outcomes and Performance Measures, which is incorporated herein by this reference, made a part hereof and attached hereto as "Attachment A -6 ". Contributions shall consist of, but are not limited to, completing requests from the HCP Regional Office to provide county specific data related to resources and needs of the population of CYSHCN and participation in trainings or other learning activities sponsored by the State Genetics Implementation Grant in order to support families and local providers in understanding and accessing recommended follow up. 3. The Contractor shall work collaboratively with the State's delegated HCP Regional Office (RO) staff for: orientation and training of new staff, as needed; consultation on HCP policies and procedures; consultation and technical assistance on community systems building efforts and community needs assessment activities, as needed; and for ensuring adequate and timely communication with the HCP Regional Office multidisciplinary team and by meeting as least once annually all together for a multi -county team meeting. 4. Contractor shall work collaboratively with the State's delegated HCP Regional Office (RO) staff for consultation, technical assistance, oversight and training on documentation in HCP /Clinical Health Information Record of Patients (HCP /CHIRP) data base and to ensure that all HCP /CHIRP database users follow the HCP /CHIRP database policies and procedures in the HCP Policy and Procedure Manual and CHIRP User Guide. 5. Contractor shall follow the HCP /CHIRP Security policy and procedures in the CHIRP User Guide and HCP Policy and Procedure Manual, 6. The HCP /CHIRP database, as provided by HCP, shall be used to document the contractor's core public health services that support meeting the Maternal Child Health Six Outcomes for Children with Special Health Care Needs. 7. Contractor's "Five -Year Community Health Assessment Report", which is referenced within the County Nursing Service contract Scope of Work, shall include county's population of children with special health care needs (CSHCN). The assessment report shall also include information regarding the resources, gaps and barriers in support and health care systems for the population of CSHCN. The Office of Local Liaison shall share the information provided in the report with the HCP program. 8. The Office of Local Liaison shall shared the county's "Annual Community Health Plan" with the HCP program. The Contractor shall serve families who are determined to fall under the MCH definition of CSHCN: "Children with special health care needs are those who have or are at risk for a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally." (Developed by the Federal Bureau of Maternal Child Health in 1995.) Recipients served shall be children residing or whose families have residence in Eagle County. 10. If the Contractor has agreed to provide Traumatic Brain Injury services under this Task Order, then the Contractor shall provide care coordination for families who have children with Traumatic Brain Injury (TBI) through the TBI Trust Fund Pilot Project as part of the HCP multi -county region in accordance with the following process: A. The Care Coordinator shall receive notification from the HCP State Office of referrals and provide care coordination for up to one (1) year for each child. Page 3 of 5 B. The Care Coordinator shall contact the family to set up an appointment to develop a care coordination plan. C. The Care Coordinator shall develop a care coordination plan, that is reasonable to accomplish within one (1) year, by reviewing the needs described on the TBI Trust Fund application, completing a standardized assessment of client and family, and asking the family to describe their priority wants or needs. D. The Care Coordinator shall complete the HCP Care Coordination Plan Form, sign the plan and obtain a signature from the family. E. The Care Coordinator shall utilize the HCP RO multi - disciplinary team for care coordination assistance. F. Upon obtaining a signed care coordination plan, the Care Coordinator shall submit a TBI Care Coordination Invoice, attached hereto as "Exhibit C" to: Rasa Eglite Prevention Services Division Colorado Department of Public Health and Environment PSD- HCP -A4 4300 Cherry Creek Drive South Denver, CO 80246 G. The Care Coordinator shall implement the care coordination plan. H. The Care Coordinator shall enter, or request assistance from the HCP RO to enter, demographic information, registration, status, referrals, concerns, and encounters into the HCP /CHIRP database to document care coordination plan, progress of activities, and outcomes. I. The Care Coordinator shall have care coordination plans available for Audit purposes. J. The Care Coordinator shall inform families of the family satisfaction survey to be sent by the state to families that received care coordination at the end of the one -year period and encourage them to respond. K. The Contractor and Care Coordinator shall comply with any and all local agency HIPAA regulations; take all appropriate steps to maintain client confidentiality; and obtain any necessary written permissions or agreements for data analysis or disclosure of protected health information, in accordance with the Health Insurance Portability and Accountability Act of 1996 ( HIPAA) regulations, including, but not limited to, authorizations, data use agreements, business associate agreements, as necessary. Failure to comply with any applicable provision of HIPAA shall constitute a breach of this Task Order. 11. Care Coordinators shall follow the policies and procedures in the "HCP Policies and Procedures Manual ". 12. Contractor shall engage in defined core public health activities designed to enhance the health status of children with special health care needs. These activities may include direct, enabling, population -based, or infrastructure building activities as described in "Attachment A -1 ". Page 4 of 5 13. The Contractor agrees that any charges for attendance and services at specialty clinics sponsored by HCP must conform to the "Clinic Support Fee Schedule" for HCP Clinics, as defined in "Attachment A -7" and any subsequent amendments thereto, incorporated herein by this reference, made a part hereof and attached hereto. 14. The Contractor shall retain and use all HCP Specialty Clinic revenues generated by the contractor to support HCP clinic activities such as clinic supplies, clinic equipment, clinic furniture, or parent professional stipends. Page 5 of 5 MCHB /DSCH 10/20/97 CORE PUBLIC HEALTH SERVICES DELIVERED BY MCH AGENCIES DIRECT HEALTH CARE SERVICES: (GAP FILLING) Examples: \ Basic Health Services, and Health Services for CSHCN ENABLING SERVICES: Examples: Transportation, Translation, Outreach, Respite Care, Health Education, Family Support Services, Purchase of Health Insurance, Case Management, Coordination with Medicaid, WIC, and Education POPULATION -BASED SERVICES: Examples: Newborn Screening, Lead Screening, Immunization, Sudden Infant Death Syndrome Counseling, Oral Health, Injury Prevention, Nutrition and Outreach /Public Education INFRASTRUCTURE BUILDING SERVICES: Examples: Needs Assessment, Evaluation, Planning, Policy Development, Coordination, Quality Assurance, Standards Development, Monitoring, Training, Applied Research, Systems of Care, and Information Systems Page I of 5 Attachment A -1 DEFINITIONS OF THE FOUR TYPES OF SERVICES BY WHICH THE CORE PUBLIC HEALTH SERVICES ARE PROVIDED BY MATERNAL AND CHILD HEALTH PROGRAMS AS DEFINED BY THE MATERNAL AND CHILD HEALTH BUREAU As of October 1, 2003 1. Direct Health Care Services Direct health care services are defined as basic health services. Such services are generally delivered "one on one" between a health professional and a patient in an office, clinic or emergency room. Basic services include what most consider to be ordinary medical care, inpatient and outpatient medical services, allied health services, drugs, laboratory testing, x -ray services, dental care, and pharmaceutical products and services. State Title V programs may support services such as prenatal care, child health, school health and family planning by directly operating programs or by funding local providers. Direct health care services also include health care services for children with special needs. Enabling Services Enabling services are defined as services that allow or provide for access to and the derivation of benefits from the array of basic health care services. Enabling services include transportation, translation, outreach, respite care, health education, family support services, purchase of health insurance, case management, and coordination of care. These kinds of services are especially necessary for the low - income population which is disadvantaged, geographically or culturally isolated, and for those with special and complicated health needs. Population -Based Services Population -based services are defined as services which are intended and available for the entire population, rather than for a selected group of individuals. Disease, prevention, health promotion and statewide outreach come under this heading. Oral health, injury prevention, nutrition and outreach and public education are topics which also belong in this category. Population -based services are generally available for women and children regardless of whether they receive care in the public or private sector or whether or not they have health insurance. Infrastructure Building Services Infrastructure building services are defined as those services that are directed at improving and maintaining the health status of a population. Included among those services are development and maintenance of health systems, standards, and guidelines, training, data, and planning. Needs assessment, evaluation, policy development, quality assurance, information systems; and applied research are all contained within the infrastructure umbrella. Page 2 of 5 Core Public Health Services Local Activities for Prenatal Care Direct Services • Provision of prenatal care /family planning services EnablinIZ Services • PN+ program services/Nurse Family Partnership Services • Medicaid /CHP+ information /enrollment • Translation services • Transportation • Prenatal care /resource referrals and /or care coordination • Client health education regarding breastfeeding, seat belts, immunization, smoking cessation, etc. Population -Based Services • Prenatal Weight Gain Campaign • Unintended Pregnancy Prevention projects • Breastfeeding Promotion campaign • Medicaid /CHP+ countywide outreach Infrastructure BuildinIZ • MCH community needs assessment • Perinatal Periods of Risk Analysis • Local MCH Plans, progress reports and evaluations • Local Prenatal/ Prenatal Plus /PRAMS data collection and analysis Page 3 of 5 Core Public Health Services Local Activities for Children and Adolescents Direct Services • Well Child Care for Undocumented Kids • Primary care in School -Based Health Centers • Immunization Clinics Enabling Services • Health education regarding breastfeeding, seatbelts, immunization, smoking cessation, etc. • CHP+ & Medicaid Outreach & Enrollment • Translation Services • Plans for Locating a Clinic in a School to Increase Access • Client Health • Education re: pregnancy prevention, fitness, nutrition, motor vehicle safety, immunizations, substance abuse, etc. Population Based Services • Breastfeeding Promotion campaign • Medicaid /CHP+ county-wide outreach • Public education social marketing related to child abuse prevention, injury prevention, importance of immunizations, etc. • Car seat safety checks • Working with schools to improve nutrition, fitness, health education Infrastructure Services • Community Needs Assessment; Planning and Evaluation • Policy Development • Quality Assurance (e.g. working with private immunization providers & child care providers) • Coalition Participation • Working with School Health Team and Early Childhood Specialists to Identify and Plan to Address Unmet Needs • Monitoring; Training Staff, Parents, Community Professionals Page 4 of 5 Core Public Health Services Local Activities for Children and Youth with Special Health Care Needs Direct Services • Provision of multi - disciplinary clinical services at HCP Specialty Clinics, D &E clinics Enabling Services • Intensive Individual Care Coordination services- Colorado Traumatic Brain Injury Trust Fund Program, HCP Clinics, Contracted Managed Care Organizations, families with no other source for care coordination • Information, resource and referral to all families, providers, organizations • Family Advocacy Population Based Services • Tracking and follow -up of Newborn Metabolic Screening • Tracking and follow -up of Newborn Hearing Screening • Tracking and monitoring for CRCSN Notification program • Gap filling screening- Newborn Hearing, Early Vision • Medical Home training, awareness campaign • Medicaid /CHP + /SSI outreach • Public Education- Newborn Hearing Screening, Early Vision, Developmental Screening (including mental and emotional), Infrastructure Services • Administration of Specialty and D &E Clinics • Needs assessment, Planning, & Evaluation and reporting- HERMAN, other • Data Collection /analysis- HCP /CHIRP, HERMAN, State and National data. • Interagency & inter - organizational agreements- Part C, Respite programs, other • Participate in development of locaVstate Data Systems- HCP /CHIRP, NEST • Participate in state /local standard development and dissemination- NB Hearing Screening and Follow Up, Early Vision Screening and Follow Up, Care Coordination • Participate in interagency workgroups to provide leadership for priority setting, planning & policy development Page 5 of 5 Attachment A -2 MATERNAL AND CHILD HEALTH CORE PUBLIC HEALTH SERVICES BUDGET APPLICATION AND EXPENDITURE REPORT CONTRACTOR: INSTRUCTIONS: When completing this form consider the Local Activities guidance in Attachment A -I and allocate the associated costs and percentages for your agency. Please indicate which report this form is being submitted for by lacing a check mark in the box located in front of the report's name. ' Budget Expenditure Report: ue Date: December I, 2006 (For The Period Of October 1, 2005 through September 30, 2006) lease provide actual numbers for how the funds were used in the period of October 1, 2005 through September 30, 2006. L_j Budget Application: Due Date: May 1, 2007 (For The Period of October 1, 2007 through September 30, 2008) Based on your county plan, please estimate the following based on your MCH funding formula contract amounts for the period of October 1, 2007 through September 30, 2008. MATERNAL AND CHILD HEALTH REPORTING FOR THE CORE PUBLIC HEALTH SERVICES SECTION I AMOUNT AND PERCENTAGE ALLOCATED TO: DOLLARS PERCENTAGE CHILD AND ADOLESCENT HEALTH PRENATAL HEALTH TOTAL 100% CHILD AND ADOLESCENT PERCENTAGE ALLOCATED TO EACH SERVICE TYPE BELOW: DIRECT SERVICES ENABLING SERVICES POPULATION -BASED SERVICES INFRASTRUCTURE BUILDING SERVICES TOTAL 100% PRENATAL HEALTH PERCENTAGE ALLOCATED TO EACH SERVICE TYPE BELOW: DIRECT SERVICES ENABLING SERVICES POPULATION -BASED SERVICES INFRASTRUCTURE BUILDING SERVICES TOTAL 100% SECTION II AMOUNT OF FUNDS ALLOCATED TO: DOLLARS CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS PERCENTAGE ALLOCATED TO EACH SERVICE TYPE BELOW: DIRECT SERVICES ENABLING SERVICES POPULATION -BASED SERVICES INFRASTRUCTURE BUILDING SERVICES TOTAL 100% NOTE: Administrative costs can be allocated to each of the above categories as appropriate. Page 1 of 1 M a w aml M O m l. Cl. Cc �0 o - •(6 L O C V m O Q U C M C E 3 c c O O cc m 0 0 N U U .2:, O O j O d r U LT � Z m C a) m - in 0� = U Y L u d a O = .- '. EoE a) c Q N O w C a O •` aa) E cn .0 �C Q. = If Q J � L u) - 4) L Q Y O (6 U O O w d ca O O O ` � CU o a) U Ri �cn E m d O•� c O U C s ~ p Q) i _0 C C p ��� = 41 m ca 6 a —_ aY a) p 0 Q ++ O (n U a, E a) m w N 0 C 4? CO m C N E C .� - a N o a) c a) m I �, > cn O a) R r •% 4 Y C � r Vj U C C Cl) a i° O LL _U co C6 U .0 a) a. t6 G1 am cc =-I-- E a :3`m Q ° is c a) c � ° m c o Q a a ° Lci ca as o a) ; ° c cm c aE) V O 2 L ` L 0 L E {j.. a) Q 75 C —M C t N c O -Q) O �' N LL 0N) 6 7 m L CO C m N 7 a m 00 N C O w Cl) (� t'- = C O � O C C a�Q a 3 tea' U 0, O m C N C U C U C E N L a U r N C N c m y m W m O .�+ m c a = a) c cv E rn N c M O m l. Cl. M a w d E T a ei C0 .. m R CL I-- w O10 U a` 3 0 d _a m W 0 m z m Vl m m 3 m Q wl- z 0 U W H 0 w a J J W U W ON Ma W W 0a 0 0 Cl) O N d CL c O v 3 O c0 o � � > N ,Y m� C L V C N > Cl CL 0 Q. C ~ o N N N V Q N �{: O l6 3 N C = O � 6 0 L, V Q N to z' V V 4 w V � 'vr V � y: O o3 O 3 w. c c EE 0 3 0 d _a m W 0 m z m Vl m m 3 m Q wl- z 0 U W H 0 w a J J W U W ON Ma W W 0a 0 0 Cl) O N d CL M a d E aq Cc 3 w CA i 4 O w O w 0 0 N co = N � O M d W N = N d � G1 f/1 V t H d' o = N O U (L) .0 L O Q� 4) U R O Z c. D �S CQ: C 0 R a N 6 s 0 e c c E E 3 3 c R R c e � m m m a n. �o w� m m a a ci F F c c e m F � O 0 N a a z u a m e R w a E b y S m m o c U V m r v R 2 m � c v Q w m O O O H H vI O ♦V r wL, W w O O C O O w C O d .Q m � w C C V C ,C c ' O � V v .t co cL d � O V C C Q C w � w V m co O M CD CL Attachment A -4 MATERNAL AND CHILD HEALTH PRIORITIES, PERFORMANCE MEASURES, AND OUTCOME MEASURES As of October 1, 2005 Colorado MCH Priorities . Reduce teen pregnancy and unintended pregnancy in women of all ages 2. Improve perinatal outcomes 3. Reduce child and adolescent morbidity and increase health and safety in child care settings 4. Reduce overweight among children and adolescents, addressing physical activity and nutritional habits 5. Improve efforts to reduce unintentional and intentional injury, addressing motor vehicle crashes, suicide, child abuse and other violence 6. Improve immunization rates for all children 7. Increase access to health care (including behavioral health care) 8. Improve state and local infrastructure by increasing capacity to analyze data, carry out evaluations, develop quality standards, and assure availability of services to all children, including children with special health care needs 9. Reduce substance abuse (alcohol, tobacco, and drugs) 10. Improve oral health and access to oral health care National Performance Measures 1. The percent of infants who are screened for conditions mandated by their State - sponsored newborn screening programs (e.g. phenylketonuria and hemoglobinopathies) and receive appropriate follow -up and referral as defined by their state 2. The percent of children with special health care needs age 0 to 18 years whose families partner in decision making at all levels and are satisfied with the services they receive 3. The percent of children with special health care needs age 0 to 18 who receive coordinated, ongoing comprehensive care within a medical home 4. The percent of children with special health care needs age 0 to 18 whose families have adequate private and /or public insurance to pay for the services they need 5. The percent of children with special health care needs age 0 to 18 whose families report the community- based service systems are organized so they can use them easily 6. The percent of youth with special health care needs who received the services necessary to make a transition to all aspects of adult life Pagel of 3 7. The percent of children of 19 to 35 month olds who have received full schedule of age appropriate immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Hemophilus Influenza, and Hepatitis B 8. The rate of birth (per 1,000) for teenagers aged 15 through 17 years 9. Percent of third grade children who have received protective sealants on at least one permanent molar tooth 10. The rate of deaths to children aged 14 and younger caused by motor vehicle crashes per 100,000 children it. Percentage of mothers who breast feed their infants at hospital discharge 12. Percentage of newborns who have been screened for hearing impairment before hospital discharge 13. Percent of children without health insurance 14. Percent of potentially Medicaid - eligible children who have received a service paid by the Medicaid program 15. The percent of very low birth weight infants among all live births 16. The rate (per 100,000) of suicide deaths among youths 15 through 19 17. Percent of very low birth weight infants delivered at facilities for high -risk deliveries and neonates 18. Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester State Performance Measures 1. The proportion of children and adolescents attending SBHCs 2. The percent of Medicaid - eligible children who receive dental services 3. The percent of women with inadequate weight gain during pregnancy 4. The rate of birth (per 1,000) for Latinal teenagers age 15 -17 5. Motor vehicle death rate 15 -19 6. Percent of mothers smoking during the 3 months before pregnancy 7. Percent of children ages 2 -14 whose BMI >85% of normal weight for height 8. The percent of children who have difficulty with emotions, concentration, or behavior 9. Percentage of center -based child care programs using a child care nurse consultant 10. The proportion of high school students reporting binge drinking in the past month Page 2 of 3 1. Nationally Chosen Outcome Measures I. The infant mortality rate per 1,000 live births 2. The ratio of the black infant mortality rate to the white infant mortality rate 3. The neonatal mortality rate per 1,000 live births 4. The postneonatal mortality rate per 1,000 live births 5. The perinatal mortality rate per 1,000 live births State Chosen Outcome Measure The low birth weight rate per 1,000 live births Revised June 23, 2005 Page 3 of 3 MATERNAL AND CHILD HEALTH Attachment A -5 TEN ESSENTIAL PUBLIC HEALTH SERVICES TO PROMOTE MATERNAL AND CHILD HEALTH I. Assess and monitor maternal and child health status to identify and address problems. 2. Diagnose and investigate health problems and health hazards affecting women, children, and youth. 3. Inform and educate the public and families about maternal and child health issues. 4. Mobilize community partnerships between policymakers, health care providers, families, the general public, and others to identify and solve maternal and child health problems. 5. Provide leadership for priority- setting, planning, and policy development to support community efforts to assure the health of women, children, youth and their families. 6. Promote and enforce legal requirements that protect the health and safety of women, children, and youth, and ensure public accountability for their well- being. 7. Link women, children, and youth to health and other community and family services, and assure access to comprehensive, quality systems of care. 8. Assure the capacity and competency of the public health and personal health workforce to effectively address maternal and child health needs. 9. Evaluate the effectiveness, accessibility, and quality of personal health and population -based maternal and child health services. 10. Support research and demonstrations to gain new insights and innovative solutions to maternal and child health - related problems. Page I of I Attachment A -6 HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS (HCP) 6 CORE OUTCOMES AND PERFORMANCE MEASURES As of October 1, 2003 Outcome #1: Families of children with special health care needs (CSHCN) will partner in decision making at all levels, and will be satisfied with the services they receive. l . Percent of families of CSHCN reporting satisfaction with the quality of: regular source of primary care, getting referrals and appointments for needed services, coordination between primary and specialty care overall services. 2. Percent of parents of CSHCN who report satisfaction with their level of invoIvement/input in setting concerns and priorities to make decisions about their child's care plan. 3. Percent of parents of CSHCN who report knowing the steps to take when they are not satisfied with the services their child /family receives. 4. Number of parents of CSHCN who are supported financially for their involvement in state and local activities. 5. Number of parents of CSHCN who report that they are effective partners in policymaking at the state and local levels. Outcome #2: All children with special health care needs will receive coordinated ongoing comprehensive care within a medical home. 1. Percent of CSHCN with a regular source of primary medical care through a primary care provider. 2. Percent of CSHCN whose regular source of care communicates in a way that is clear and understandable to the family. 3. Percent of parents whose regular source of primary medical care identifies, discusses, and addresses the comprehensive needs of their child and family. 4. Percent of CSHCN whose regular source of primary medical care ensures age- appropriate well -child checks, including: vision, hearing, developmental, behavioral /mental health, oral health, newborn screening, immunizations. 5. Percent of parents of CSHCN who receive referrals and assistance from their regular source of primary medical care in accessing needed/desired services. Outcome #3: All families of children with special health care needs will have adequate private and /or public insurance to pay for the services they need. Percent of CSHCN with insurance that covers costs of needed services, including: mental health, dental care, age- appropriate well -child checks, durable medical equipment, ancillary services, non - durable medical supplies, care coordination, prescriptions, specialty care, related therapies (e.g., PT, OT, speech/language, audiology), in -home nursing. Page I of 3 Amount of out -of- pocket costs paid by families of CSHCN, including costs of: mental health, dental care, age- appropriate well -child checks, durable medical equipment, ancillary services, non - durable medical supplies, respite care, transportation, care coordination, prescriptions, specialty care, related therapies (e.g., PT, OT, speech/language, audiology), in -home nursing, home modifications, car /van modifications. Percent of CSHCN who can choose the providers of their choice. 4. Percent of CSHCN whose insurance provides: timely approval for needed care, overall parental satisfaction, clear information, about coverage resources, and complaint procedures to providers and parents. Outcome #4: All children will be screened early and continuously for special health care needs. 1. Percent of infants whose mothers began prenatal screening in the first trimester of pregnancy, for smoking, alcohol, drugs, tests for birth defects, HW, physical abuse. 2. Percent of infants and families being tracked for special health care needs and developmental delays. 3. Percent of children receiving age- appropriate well -child checks including: vision, hearing, developmental, behavioral, mental health, oral health, metabolic, and EPSDT (if implemented in state). 4. Percent of children receiving needed follow -up due to failed screening or risk factors: vision, hearing, developmental, behavioral, mental health, oral health, and metabolic. Outcome #5: Services for children with special health care needs and their families will be organized in ways that families can use them easily. 1. Percent of parents of CSHCN who have a single coordinated service plan that involves all providers and a lead service coordinator who communicates with the family. 2. Percent of parents of CSHCN who report that they are able to access comprehensive services for their child and family. 3. Percent of parents of CSHCN who have specialty care available in their region of the state. 4. The degree to which the state service system has an enrollment/eligibility process that links families of CSHCN (and their medical home) with a wide variety of public and private services and resources. 5. Number of private /public partnerships to provide community- based, comprehensive medical services for CSHCN, e.g., data sharing, contracts, MOAs. Outcome #6: All youth with special health care needs (SHCN) will receive the services necessary to make appropriate transitions to adult health care, work and independence. Percent of youth with SHCN who by age 14 have a transition plan that addresses employment, transportation, housing, independent living, physical and mental health and necessary accommodations; and percent of youth with SHCN by age 16 have a transition plan that includes appropriate agencies as part of the transition planning team. Percent of youth with SHCN whose regular source of primary medical care facilitates the transition from pediatric to adult providers. Page 2 of 3 Percent of adult health care providers who are prepared to serve youth with SHCN. 4. Percent of youth who report satisfaction with the information and training they received to make informed decisions about their health care and other services. Percent of youth with SHCN who receive necessary services /supports by age 21: Health insurance, Post- secondary education, Employment, Transportation, Housing, Personal care attendant, SSI, SSA - related work incentives, e.g. PASS, 1619 a & b. Last Revised June 17, 2003 Page 3 of 3 Attachment A -7 HEALTH CARE PROGRAM FOR CHILDREN WITH SPECIAL NEEDS (HCP) CLINIC SUPPORT FEE SCHEDULE Effective October 1, 2005 The Health Care Program for Children with Special Needs (HCP) is committed to the HCP Sponsored Specialty Clinics. We want to ensure that throughout Colorado families have access to specialty care. To this end, a Clinic Support Fee helps to provide vital support to the local infrastructure necessary to operate the HCP Specialty Clinics. The sliding fee schedule affects families with or without insurance, including CHP +. Medicaid clients do not pay a clinic support fee. This policy does not apply to the statewide Diagnostic and Evaluation (D &E) Clinic System. Pediatric Audiology /Otology, Pediatric, Pediatric Orthopedic, Pediatric Cardiology, Pediatric Neurology, and Pediatric Rehabilitation Clinics A. Families, except those on Medicaid, will be assessed a clinic support fee. B. Clients will be charged a clinic support fee according to their Federal Poverty Level (FPL) as follows: I. No charge for families at or below 100% FPL 2. $5 fee per visit for a rating of 101 - 133 %FPL 3. $10 fee per visit for a rating of 134 to 185% FPL 4. $30 fee per visit for a rating of 186 to 211% FPL 5. $50 fee per visit for a rating of 212 to 399% FPL 6. $75 fee per visit for a rating of 400 to 450% FPL 7. $100 fee per visit for a rating greater than 450% FPL C. All clinic patients must be registered with HCP and complete a financial statement included in the HCP application. Families who choose not to complete the financial statement will be charged the maximum fee on the schedule per visit. D. Each child that has an individual appointment time will be charged a clinic support fee. E.G., The family with two children that have two separate appointment slots would be charged two fees. E. The fees collected are to support HCP clinic activities such as: clinic supplies, clinic equipment, clinic furniture or parent/professional stipends. A record of fees collected and how they are dispersed is to be kept by the clinic coordinator and the Team Leader. II. Pediatric Clinics Children attending an HCP Pediatric Clinic: A. Upon referral from the child's PCP requesting a diagnostic evaluation and /or continuing consultation from the pediatrician, the child may be seen in the HCP Pediatric Clinic. B. Families not on Medicaid will be charged a clinic support fee. (HCP is providing access for these families, but not paying for services to children.) C. Family pays all labs and x -rays ordered out of clinic. Revised April 2005 Page 1 of 1 EXHIBIT B HIPAA BUSINESS ASSOCIATE Memorandum of Understanding The parties to this Business Associate Memorandum of Understanding ( "MOU ") are the Colorado Department of Public Health and Environment ( "State" or "Department ") and the Board of County Commissioners of Eagle County ( "Contractor," or "Associate "). This MOU is effective as of October 1, 2006 or the compliance date of the Privacy Rule (defined below), whichever first occurs (the "MOU Effective Date "). RECITALS A. The Department is a business associate of the Colorado Department of Human Services ( "Covered Entity" or "CE ") and as such must comply with applicable requirements Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. § 1320d — 3120d- 8 ( "HIPAA "), which requires that if the Department subcontracts any covered function and discloses protected health information to a subcontractor, the Department must enter into a business associate agreement with such a subcontractor. B. The Department wishes to disclose certain information to Associate pursuant to the terms of the Contract, some of which may constitute Protected Health Information ( "PHI") (defined below). C. Department and Associate intend to protect the privacy and provide for the security of PHI disclosed to Associate pursuant to the Contract in compliance with the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. § 1320d — 1320d -8 ( "HIPAA ") and its implementing regulations thereunder by the U.S. Department of Health and Human Services (the "Privacy Rule ") and other applicable laws, as amended. D. As part of the HIPAA regulations, the Privacy Rule requires the Department to enter into a contract 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 MOU. E. Authority exists in the Law and Funds have been budgeted, appropriated, and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment in Fund Code(s) 100, Organizational Unit Code(s) 6810, Appropriation Code(s) 609, Program Code(s) 9017, Function Code(s) FLWT, Object Code 5120, and Grant Budget Line Code(s) OF61? under Contract encumbrance number PO FLA HCP07000001 for Traumatic Brain Injury (TBI) Services. All required approvals, clearances, and coordination have been accomplished from and with all appropriate agencies. Colorado MOU — Subcontracting Covered Functions Rev. 3/04 Page 1 of 10 F. Required approval, clearance and coordination have been accomplished from and with appropriate agencies. The parties agree as follows: Definitions. a. Except as otherwise defined herein, capitalized terms in this MOU shall have the definitions set forth in the HIPAA Privacy Rule at 45 C.F.R. Parts 160 and 164, as amended. In the event of any conflict between the mandatory provisions of the Privacy Rule and the provisions of this MOU, the Privacy Rule shall control. Where the provisions of this MOU differ from those mandated by the Privacy Rule, but are nonetheless permitted by the Privacy Rule, the provisions of this MOU 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 Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.501. C. "Protected Information" shall mean PHI provided by CE to the Department or to Associate or created or received 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 MOU 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. 2. Statement of Work and Responsibilities. The Statement of Work for purposes of this MOU is contained in the Contract between the Department and Associate dated September 6, 2006. 3. Payment Amount and Billing Procedure. The consideration for Associate performing its obligations under Section 2 above, is set forth in the Contract between the Department and Contractor dated September 6, 2006. 4. Term. The term of this MOU begins on the MOU Effective Date, as set forth in the opening paragraph of this MOU, and runs through and including September 30, 2007. Colorado MOU — Subcontracting Covered Functions Rev. 3/04 Page 2 of 10 Obligations of Associate. a. Permitted Uses. Associate shall not use Protected Information except for the purpose of performing Associate's obligations under and as permitted by the terms of this MOU. Further, Associate shall not use Protected Information in any manner that would constitute a violation of the Privacy Rule 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. Additional provisions, if any, governing permitted uses of Protected Information are set forth in Attachment B -1. b. Permitted Disclosures. Associate shall not disclose Protected Information in any manner that would constitute a violation of the Privacy Rule if disclosed by CE, except that Associate may disclose Protected Information: (i) in a manner permitted pursuant to this MOU; (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 164.5020)(1). To the extent that Associate discloses Protected Information to a third party, Associate must obtain, prior to making any such disclosure:(i) reasonable assurances from such third party that such Protected Information will be held confidential as provided pursuant to this MOU and only disclosed as required by law or for the purposes for which it was disclosed to such third party; and (ii) an agreement from such third party to notify Associate within one business day of any breaches of confidentiality of the Protected Information, to the extent it has obtained knowledge of such breach. Additional provisions, if any, governing permitted disclosures of Protected Information are set forth in Attachment B -l. C. Appropriate Safeguards, Associate shall implement appropriate safeguards as are necessary to prevent the use or disclosure of Protected Information otherwise than as permitted by this MOU. 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. d. Reporting of Improper Use or Disclosure. Associate shall report to the Department in writing any use or disclosure of Protected Information other than as provided for by this MOU within three (3) business days of becoming aware of such use or disclosure. e. Associate's Agents. If Associate uses one or more subcontractors or agents to provide services under this MOU, and such subcontractors or agents receive or have access to Protected Information, each subcontractor or agent shall sign an agreement with Associate containing substantially the same provisions as this MOU and further identifying CE as a third party beneficiary with rights of enforcement and indemnification from such subcontractors or agents in the event of any violation of such subcontractor or agent agreement. Associate shall implement and maintain appropriate sanctions against agents and subcontractors that violate such restrictions and conditions and shall mitigate the effects of any such violation. Colorado MOU — Subcontracting Covered Functions Rev. 3/04 Page 3 of 10 f. Access to Protected Information. Associate shall make Protected Information maintained by Associate or its agents or subcontractors in Designated Record Sets available to the Department for inspection and copying within seven (7) business days of a request by the Department to enable CE to fulfill its obligations to permit individual access to PHI under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.524. g. Amendment of PHI. Within seven (7) business days of receipt of a request from the Department for an amendment of Protected Information or a record about an individual contained in a Designated Record Set, Associate or its agents or subcontractors shall make such Protected Information available to CE for amendment and incorporate any such amendment to enable CE to fulfill its obligations with respect to requests by individuals to amend their PHI under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.526. If any individual requests an amendment of Protected Information directly from Associate or its agents or subcontractors, Associate must notify the Department in writing within three (3) business days of the receipt of the request. Any denial of amendment of Protected Information maintained by Associate or its agents or subcontractors shall be the responsibility of CE. h. Accounting Rights. Within seven (7) business days of notice by the Department of a request for an accounting of disclosures of Protected Information, Associate and its agents or subcontractors shall make available to the Department the information required to provide an accounting of disclosures to enable CE to fulfill its obligations under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.528. As set forth in, and as limited by, 45 C.F.R. Section 164.528, Associate shall not provide an accounting to CE of disclosures: (i) to carry out treatment, payment or health care operations, as set forth in 45 C.F.R. Section 164.506; (ii) to individuals of Protected Information about them as set forth in 45 C.F.R. Section 164.502; (iii) pursuant to an authorization as provided in 45 C.F.R. Section 164.508; (iv) to persons involved in the individual's care or other notification purposes as set forth in 45 C.F.R. Section 164.510; (v) for national security or intelligence purposes as set forth in 45 C.F.R. Section 164.512(k)(2); (vi) to correctional institutions or law enforcement officials as set forth in 45 C.F.R. Section 164.512(k)(5); (vii) incident to a use or disclosure otherwise permitted by the Privacy Rule; (viii) as part of a limited data set under 45 C.F.R. Section 164.514(e); or (ix) disclosures prior to April 14, 2003.. Associate agrees to implement a process that allows for an accounting to be collected and maintained by Associate and its agents or subcontractors for at least six (6) years prior to the request, but not before the compliance date of the Privacy Rule. At a minimum, such information shall include: (i) the date of disclosure; (ii) the name of the entity or person who received Protected Information and, if known, the address of the entity or person; (iii) a brief description of Protected Information disclosed; and (iv) a brief statement of purpose of the disclosure that reasonably informs the individual of the basis for the disclosure, or a copy of the individual's authorization, or a copy of the written request for disclosure. In the event that the request for an accounting is delivered directly to Associate or its agents or subcontractors, Associate shall within five (5) business days of the receipt of the request forward it to the Department 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 5(b) of this MOU. Colorado MOU — Subcontracting Covered Functions Rev. 3104 Page 4 of 10 i. Governmental Access to Records Associate shall 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 compliance with the Privacy Rule. Associate shall provide to the Department a copy of any Protected Information that Associate provides to the Secretary concurrently with providing such Protected Information to the Secretary. j. Minimum Necessary. Associate (and its agents or subcontractors) 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 Privacy Rule including, but not limited to, 45 C.F.R. Sections 164.502(b) and 164.514(d). k. Data Ownership. Associate acknowledges that Associate has no ownership rights with respect to the Protected Information. 1. Retention of Protected Information. Except as provided in Section 7(e) of this MOU, Associate and its subcontractors or agents shall retain all Protected Information throughout the term of this MOU and shall continue to maintain the information required under Section 5(h) of this MOU for a period of six (6) years after termination of the Contract. m. Notification of Breach. During the term of this MOU, Associate shall notify the Department within two business days of any suspected or actual breach of security, intrusion or unauthorized use or disclosure of PHI and /or any actual or suspected use or disclosure of data in violation of any applicable federal or state laws or regulations. 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. n. Audits, Inspection and Enforcement. Within seven (7) business days of a written request by the Department, Associate and its agents or subcontractors shall allow the Department to conduct a reasonable inspection of the facilities, systems, books, records, agreements, policies and procedures relating to the use or disclosure of Protected Information pursuant to this MOU for the purpose of determining whether Associate has complied with this MOU; provided, however, that: (i) Associate and the Department shall mutually agree in advance upon the scope, timing and location of such an inspection; (ii) the Department shall protect the confidentiality of all confidential and proprietary information of Associate to which the Department has access during the course of such inspection; and (iii) the Department shall execute a nondisclosure agreement, upon terms mutually agreed upon by the parties, if requested by Associate. The fact that the Department inspects, or fails to inspect, or has the right to inspect, Associate's facilities, systems, books, records, agreements, policies and procedures does not relieve Associate of its responsibility to comply with this MOU, nor does the Department's (i) failure to detect or (ii) detection, but failure to notify Associate or require Associate's remediation of any unsatisfactory practices, constitute acceptance of such practice or a waiver of the Department's enforcement rights under this MOU. Colorado MOU — Subcontracting Covered Functions Rev. 3/04 Page 5of10 o. Safeguards During Transmission. Associate shall be responsible for using appropriate safeguards to maintain and ensure the confidentiality, privacy and security of Protected Information transmitted to CE pursuant to this MOU, in accordance with the standards and requirements of the Privacy Rule, until such Protected Information is received by the Department, and in accordance with any specifications set forth in Attachment B -1. p. Restrictions and Confidential Communications. Within seven (7) business days of notice by the Department of a restriction upon uses or disclosures or request for confidential communications pursuant to 45 C.F.R. 164.522, Associate will restrict the use or disclosure of an individual's Protected Information, provided Associate has agreed to such a restriction. 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 Department so that the Department can coordinate with the CE and prepare a timely response to the requesting individual and provide direction to Associate. 6. Obligations of the Department and CE. a. Safeguards During Transmission. The Department and CE shall be responsible for using appropriate safeguards to maintain and ensure the confidentiality, privacy and security of PHI transmitted to Associate pursuant to this MOU, in accordance with the standards and requirements of the Privacy Rule, until such PHI is received by Associate, and in accordance with any specifications set forth in Attachment B -1. b. Notice of Changes. The Department shall provide Associate with a copy of CE's notice of privacy practices produced in accordance with 45 C.F.R. Section 164.520, as well as any subsequent changes or limitation(s) to such notice, to the extent such changes or limitations may effect Associate's use or disclosure of Protected Information. The Department shall provide Associate with any changes in, or revocation of, permission to use or disclose Protected Information, to the extent 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, the Department 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. CE may effectuate any and all such notices of de- identified information via posting on CE's web site. Associate shall review CE's designated web site for notice of changes to CE's HIPAA privacy policies and practices on the last day of each calendar quarter. 7. Termination. a. Without Cause. Either of the parties shall have the right to terminate this MOU by giving the other party twenty -one (2 1) calendar days notice. If notice is given, the MOU will terminate at the end of twenty -one (21) calendar days, and the liabilities of the parties hereunder for further performance of the terms of the MOU shall thereupon cease, but the parties shall not be released from duty to perform up to the date of termination. Colorado MOU — Subcontracting Covered Functions Rev. 3/04 Page 6of10 b. Material Breach. Any material breach by Associate of any provision of this MOU, as determined by the Department, shall be grounds for immediate termination of the Contract by the Department. Any dispute concerning the performance of this MOU which cannot be resolved at the divisional level shall be referred to superior departmental management staff designated by each department. Failing resolution at that level, disputes shall be presented to the executive directors of each department for resolution. Failing resolution by the executive directors, the dispute shall be submitted in writing by both parties to the State Controller, whose decision on the dispute shall be final. This dispute resolution mechanism is in addition to, and not in lieu of, any other reporting or other requirement of federal or state law concerning alleged privacy violations. C. Reasonable Steps to Cure Breach If the Department 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 MOU or another arrangement and does not terminate this MOU pursuant to Section 7(a), then the Department shall take reasonable steps to cure such breach or end such violation, as applicable. If the Department's efforts to cure such breach or end such violation are unsuccessful, the Department shall either (i) terminate this MOU, if feasible or (ii) if termination of this MOU is not feasible, the Department shall report Associate's breach or violation to the CE, the Colorado Attorney General's Office and to the Secretary of the U.S. Department of Health and Human Services. d. Judicial or Administrative Proceedings. Either party may terminate this MOU, effective immediately, if (i) the other party is named as a defendant in a criminal proceeding for a violation of HIPAA, the HIPAA Regulations or other security or privacy laws or (ii) a finding or stipulation that the other party has violated any standard or requirement of HIPAA, the HIPAA Regulations or other security or privacy laws is made in any administrative or civil proceeding in which the party has been joined. e. Effect of Termination. (1) Except as provided in paragraph (2) of this subsection, upon termination of this MOU, for any reason, Associate shall return or destroy all Protected Information that Associate or its agents or subcontractors still maintain in any form, and shall retain no copies of such Protected Information. If Associate elects to destroy the PHI, Associate shall certify in writing to the Department that such PHI has been destroyed. (2) If Associate believes that returning or destroying the Protected Information is not feasible, Associate shall promptly provide the Department notice of the conditions making return or destruction infeasible. Upon mutual agreement of the Department and Associate that return or destruction of Protected Information is infeasible, Associate shall continue to extend the protections of Sections 5(a), 5(b), 5(c), 5(d) and 5(e) of this MOU to such information, and shall limit further use of such PHI to those purposes that make the return or destruction of such PHI infeasible. Colorado MOU — Subcontracting Covered Functions Rev. 3/04 Page 7 of 10 8. No Waiver of Immunity. No term or condition of this MOU shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protection, or other provisions of the Colorado Governmental Immunity Act, CRS 24 -10 -101 et seq. or the Federal Tort Claims Act, 28 U.S.C. 2671 et seq. as applicable, as now in effect or hereafter amended. 9. Defense. To the extent any legal action against either party is not covered by the Risk Management Fund or other authorized self - insurance fund for tort claims, each party shall defend itself at its own expense in any action by third parties. 10. Disclaimer. The Department makes no warranty or representation that compliance by Associate with this MOU, HIPAA or the HIPAA Regulations 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. 11. Certification. To the extent that the Department determines an examination is necessary in order to comply with CE's legal obligations pursuant to HIPAA relating to certification of its security practices, the Department or its authorized agents or contractors, may, at the Department's expense, examine Associate's facilities, systems, procedures and records as may be necessary for such agents or contractors to certify to the Department the extent to which Associate's security safeguards comply with HIPAA, the HIPAA Regulations or this MOU. 12. Amendment. a. Amendment to Comply with Law. The parties acknowledge that state and federal laws relating to data security and privacy are rapidly evolving and that amendment of this MOU may be required to provide for procedures to ensure compliance with such developments. The parties specifically agree to take such action as is necessary to implement the standards and requirements of HIPAA, the Privacy Rule, the Final HIPAA Security regulations at 68 Fed. Reg. 8334 (Feb. 20, 2003), 45 C.F.R. § 164.314 and other applicable laws relating to the security or privacy of PHI. The parties understand and agree that the Department must receive satisfactory written assurance from Associate that Associate will adequately safeguard all Protected Information. Upon the request of either party, the other party agrees to promptly enter into negotiations concerning the terms of an amendment to this MOU embodying written assurances consistent with the standards and requirements of HIPAA, the Privacy Rule or other applicable laws. The Department may terminate the MOU upon thirty (30) days written notice in the event (i) Associate does not promptly enter into negotiations to amend this MOU when requested by the Department pursuant to this Section or (ii) Associate does not enter into an amendment to this MOU providing assurances regarding the safeguarding of PHI that CE, in its sole discretion, deems sufficient to satisfy the standards and requirements of HIPAA and the Privacy Rule. b. Amendment of Attachment B -l. Attachment B -1 may be modified or amended by mutual agreement of the parties in writing from time to time without formal amendment of this MOU. Colorado MOU — Subcontracting Covered Functions Rev. 3/04 Page 8of10 13. Assistance in Litigation or Administrative Proceedings. Associate shall make itself, and any subcontractors, employees or agents assisting Associate in the performance of its obligations under this MOU, available to the Department, at no cost to the Department up to a maximum of 30 hours, to testify as witnesses, or otherwise, in the event of litigation or administrative proceedings being commenced against the Department, CE, its directors, officers or employees based upon a claimed violation of HIPAA, the Privacy Rule or other laws relating to security and privacy of PHI, except where Associate or its subcontractor, employee or agent is a named adverse party. 14. No Third Party Beneficiaries. Nothing express or implied in this MOU is intended to confer, nor shall anything herein confer, upon any person other than the Department, CE, Associate and their respective successors or assigns, any rights, remedies, obligations or liabilities whatsoever. 15. Interpretation. This MOU shall be interpreted as broadly as necessary to implement and comply with HIPAA and the Privacy Rule. The parties agree that any ambiguity in this MOU shall be resolved in favor of a meaning that complies and is consistent with HIPAA and the Privacy Rule. 16. Survival of Certain Terms. Notwithstanding anything herein to the contrary, Associate's obligations under Section 7(d) ( "Effect of Termination ") and Section 14 ( "No Third Party Beneficiaries ") shall survive termination of this MOU and shall be enforceable by CE as provided herein in the event of such failure to perform or comply by the Associate. 17. Representatives and Notice. a. Representatives. For the purpose of this MOU, the individuals listed below are hereby designated as the parties' respective representatives. Either party may from time to time designate in writing new or substitute representatives. Colorado MOU — Subcontracting Covered Functions Rev. 3/04 Page 9 of 10 b. Notices. All required notices shall be in writing and shall be hand delivered or given by certified or registered mail to the representatives at the addresses set forth below. State/Department Representative: Name: Kathy Wafters Title: HCP Director Department and Division: Colorado Department of Public Health and Environment Prevention Services Division Address: 4300 Cherry Creek Drive South PSD- HCP -A4 Denver Colorado 80246 Contractor/Business Associate Representative: Name: Kathleen Forinash Title: Director Department and Division: Eagle County Health and Human Services Address: P. O. Box 660 Eagle CO 81631 18. Availability of Funds. Payment pursuant to this MOU, if in any part federally funded, is subject to and contingent upon the continuing availability of federal funds for the purposes hereof. If any of said federal funds become unavailable, as determined by the Department, either party may immediately terminate or seek to amend this MOU. 19. Audits. In addition to any other audit rights in this MOU, Associate shall permit the Department and any authorized federal agency to monitor and audit records and activities which are or have been undertaken pursuant to this MOU. 20. No Assignment. Except as otherwise provided, the duties and obligations of Associate shall not be assigned, delegated or subcontracted except with the express prior written consent of CE. Any subcontractors or agents used by BA to perform any services in connection with this MOU shall be subject to the requirements of this MOU. Colorado MOU — Subcontracting Covered Functions Rev. 3/04 Page 10 of 10 Attachment B -1 This Attachment sets forth additional terms to the HIPAA Business Associate MOU dated October 1, 2006, between the Colorado Department of Public Health and Environment ( CDPHE) and Board of County Commissioners of Eagle County (Associate). This Attachment may be amended from time to time as provided in Section 12(b) of the MOU. Additional Permitted Uses. In addition to those purposes set forth in Section 5(a) of the MOU, Associate may use Protected Information as follows: The Associate may disclose aggregate reports that conform to HIPAA de- identification definitions contained in HIPAA 164.514 (b) (1) or (2) 2. Additional Permitted Disclosures. In addition to those purposes set forth in Section 5(b) of the MOU, Associate may disclose Protected Information as follows: The Associate may disclose ag regate reports that conform to HIPAA de identification definitions contained in HIPAA § 164.514.(b) (1) or (2) 3. Subcontractor(s). The parties acknowledge that the following subcontractors or agents of Associate shall receive Protected Information in the course of assisting Associate in the performance of its obligations under the MOU: Associate's Health Care Program for Children with Special Needs discipline coordinator contractors 4. Receipt. Associate's receipt of Protected Information pursuant to the MOU shall be deemed to occur as follows, and Associate's obligations under the MOU shall commence with respect to such PHI upon such receipt: Delivery of copies of eligibility applications including ICD -9 diagnosis and any other information that can be used in the treatment of the traumatic brain - iniured child This information mqy be in paper or electronic format 5. Additional Restrictions on Use of Data. Associate shall comply with the following restrictions on the use and disclosure of Protected Information: N/A 6. Additional Terms. [This section may include specifications for disclosure format, method of transmission, use of an intermediary, use of digital signatures or PKI, authentication, additional security of privacy specifications, de- identification or re- identification of data and other additional terms.] The Associate will secure HIPAA- compliant authorization to allow disclosure of personally identifiable data to the CDPHE TBI Surveillance program Authorization form to be used is attached as Attachment B -1 -1 to the MOU. Colorado MOU — Subcontracting Covered Functions Rev. 3/04 Page 1 of I pppp ATTACHMENT B -1 -1 o$ Health Care Program for Children with Special Needs (HCP) Telephone: (303) 692 -2370; FAX: (303) 782 -5576 Colorado Traumatic Brain Injury (TBI) Program AUTHORIZATION TO RELEASE PATIENT INFORMATION OBTAIN FROM: (Who is releasing the information ?) RELEASE TO: (Who is receiving the information ?) Colorado Department of Public Health and Environment Colorado Department of Public Health and Environment Health Care Program for Children with Special Needs (HCP) Injury Epidemiology Program PSD- HCP -A4 Traumatic Brain Injury Surveillance Project 4300 Cherry Creek Drive South PSD4E -A4 Denver, CO 80246 -1530 4300 Cherry Creek Drive South Denver, CO 80246 -1530 SPECIFIC IDENTIFYING INFORMATION BEING REQUESTED: PATIENT NAME: ADDRESS: CITY COUNTY STATE Z1P DATE OF BIRTH: GENDER (Circle): M F RACE (Optional) PERSON AUTHORIZED TO SIGN FOR PATIENT: RELATIONSHIP TO PATIENT: ADDRESS (Ifdifferent from patient's) DATE OF HOSPITALIZATION FOR TBI: HOSPITAL NAME: PURPOSE FOR DISCLOSURE: (What is the information to be used for ?) Public health analysis. The Injury Epidemiology Program will group this information to describe children who received services, compare this group to all children hospitalized with TBI, and estimate the need for TBI services. I understand that signing this authorization is not a condition of receiving services. I understand that a copy or facsimile ofthis authorization is to be considered as valid as the original and that this authorization will expire 365 days from the date of signature. I also understand that I may revoke this authorization at any time and that I will be asked to sign the Revocation Section on the back of this form. I further understand that any action taken on this authorization prior to the rescinded date is legal and binding. I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirmin that it accurately reflects my wishes. Patient Signature Date/Time Person authorized to sign for patient Date/Time Address Relationship to Patient Phone City State Zip HCP Staff Signature/Title (if signed in person) Date/Time Pagel of 2 REVOCATION SECTION I do hereby request that this authorization to disclose personal information of Name of Patient signed by on Name of person who signed Authorization Date of Signature be rescinded effective I understand that any action taken on this (Date /Time) authorization prior to the rescinded date is legal and binding. Patient Signature I Address S tate DatelTime Person authorized to sign for patient Date/Time Relationship to Patient Phone Witness Signature/Title DatefTime Page 2 of 2 tt `I r;. liAll1L11 l.. Agency Name and Address TBI CARE COORDINATION INVOICE Client Name: HCP CHIRP Number: TBI Case Number: First Date of Contact: Date Care Plan Approved: Payment Amount 1 — [Insert month care plan is approved] $240 2- $60 3- $60 4- $60 5- $60 6- $60 7- $60 8- $60 9- $60 10- $60 11 - $60 12- $60 Maximum Amount Payable $900 Date: / / Care Coordinator Signature Make Checks Payable to: (If other than HCP RO) Mail or Fax this Invoice to: Rasa Eglite, TBI Project Manager Colorado Department of Public Health and Environment PSD- HCP -A4 4300Cherry Creek Drive South Denver, CO 80246 -1530 Phone: 303-692-2411 FAX: 303 - 753 -9249 Ethat eceived & inspecte d the goods /services invoiced & found them to be satisfactory. Approved for Payment. Date: — — — Signature Date: — — — Page 1 of I .1, EXHIBIT D TASK ORDER CHANGE ORDER LETTER [Date) Task Order Change Order Letter Number ** Contract Routing Number ** * ** * * * ** State Fiscal Year 20 ** - 20 * *, * * * * * * * * * * * * * ** Program This Task Order Change Order Letter is issued pursuant to paragraph *� *. of the Master Contract identified as contract routing number ** * * * * * * * * and paragraph *. *. of the Task Order identified as contract routing number ** * ** * * * ** and contract encumbrance number ** * ** * * * * * * * * ** between the COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT and r LEGAL NAME OF CONTRACTORI. The Task Order has been amended by Task Order Option to Renew Letter contract routing number ** * ** * * * * *, and /or Task Order Change Order Letter ** _, contract routin g number ** * ** * * * * *, if any. The Task Order, as amended, if applicable, is referred to as the "Original Task Order ". This Task Order Change Order Letter is for the current term of * * * * * * * ** ** * * ** through * * * * * * * ** ** * * * *. The maximum amount payable by the State for the work to be performed by the Contractor during this current term is increased /decreased by * * * * * * * * ** Dollars, $ *. ** for an amended total financial obligation of the State of * * * * * * * * ** DOLLARS, $* ** ( 1. The revised specifications to the original Scope of Work and the revised Budget are incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment *" and "Attachment * ". The first sentence in paragraph *_ * *. of the Original Task Order is modified accordingly. All other terms and conditions of the Original Task Order are reaffirmed. This change to the Task Order shall be effective upon approval by the State controller, or designee, or on * * * * * * * ** ** * * ** whichever is later. Please sign, date, and return all ** originals of this Task Order Change Order Letter by * * * * * * * ** ** * * ** to the attention of: * * * * * * * * * * ** * * * * * * * * * * ** Colorado Department of Public Health and Environment, 4300 Cherry Creek Drive South, Mail Code * * *- * * * - * *, Denver, Colorado 80246. One original of this Task Order Change Order Letter will be returned to you when fully approved. [LEGAL NAME OF CONTRACTOR) STATE OF COLORADO (a political subdivision of the state of Colorado) Bill Owens, Governor By: By. Name: For the Executive Director Title: DEPARTMENT OF PUBLIC HEALTH FEIN: AND ENVIRONMENT (Seal - Required) PROGRAM APPROVAL: By: ATTEST (required): By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24 -30 -202 requires that the State Controller approve all state contracts. This contract is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated to pay for the goods and /or services provided. By: Date: STATE CONTROLLER: Leslie M. Shenefelt Revised: 11/5/04 Page 1 of I e� �� ' EXHIBIT E * TASK ORDER OPTION TO RENEW LETTER ri [Date] Task Order Option to Renew Letter Number * *, Contract Routing Number" * ** * * * ** State Fiscal Year 20 ** - 20 ** * * * * * * * * * * * * * ** Proeram This Task Order Option to Renew Letter is issued pursuant to paragraph *_ * *. of the Master Contract identified by contract routing number ** * * * * * * * * and paragraph *. *, of the Task Order identified by contract routing number ** * ** * * * ** and contract encumbrance number ** * ** * * * * * * * * * *, This Task Order Option to Renew Letter is between the COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT and LEGAL NAME OF CONTRACTORI. The Task Order has been amended by Task Order Change Order Letter * *, contract routing number ** * ** * * * ** and /or Task Order Option to Renew Letter * *, contract routing number ** * ** if any. The Task Order, as amended, if applicable, is referred to as the "Original Task Order ". This Task Order Option to Renew Letter is for the renewal term of * * * * * * * ** ** * * * *, through * * * * * * * ** ** * * ** The maximum amount payable by the State for the work to be performed by the Contractor during this renewal term is * * * * * * * * ** Dollars, ( *.* *) for an amended total financial obligation of the State of * * * * * * * ** DOLLARS, This is an increase /decrease of ($ *. * *} of the amount payable from the previous term. The Budget for this renewal term is incorporated herein by this reference, made a part hereof, and attached hereto as "Attachment * ". The first sentence in paragraph *_ * *. of the Original Task Order is modified accordingly. All other terms and conditions of the Original Task Order are reaffirmed. This Task Order Option to Renew Letter is effective upon approval by the State Controller, or designee, or on * * * * * * * ** ** * * * *, whichever is later. Please sign, date, and return all ** originals of this Task Order Option to Renew Letter by * * * * * * * ** ** * * * *, to the attention of: * * * * * * * * * * ** * * * * * * * * * * * * Colorado Department of Public Health and Environment, Mail Code * * *- * * * - * *, 4300 Cherry Creek Drive South, Denver, Colorado 80246. One original of this Task Order Option to Renew Letter will be returned to you when fully approved. [LEGAL NAME OF CONTRACTOR] STATE OF COLORADO (a political subdivision of the state of Colorado) Bill Owens, Governor By: Name: Title: FEIN: (Seal - required) ATTEST (required): By: By: For the Executive Director DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PROGRAM APPROVAL: By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24 -30 -202 requires that the State Controller approve all state contracts. This contract is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated to pay for the goods and /or services provided. By: Date: STATE CONTROLLER: Leslie M. Shenefelt Revised: 11/5/04 Page I of I , , r - HGP SEP 25 2006