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HomeMy WebLinkAboutC08-168DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT ROUTING N0.09 FLA 00003 APPROVED TASK ORDER CONTRACT -WAIVER #154 This Task Order Contract is issued pursuant to Master Contract made on 01/23/07, with routing number OS FAA 00016 STATE State of Colorado for the use & benefit of the Department of Public Health and Environment Prevention Services Division Nurse Home Visitor Program 4300 Cherry Creek Drive South Denver, Colorado 80127 TASK ORDER MADE DATE: 04/21/08 PO/SC ENCUMBRANCE NUMBER PO FLA FHS0900003 TERM This Task Order shall be effective upon approval by the State Controller, or designee, or on 07/01/2008, whichever is later. The Task Order shall end on 06/30/2009. PRICE STRUCTURE: Cost Reimbursement PROCUREMENT METHOD: Exempt BID/RFP/LIST PRICE AGREEMENT NUMBER Not Applicable LAW SPECIFIED VENDOR STATUTE: Not Applicable STATE REPRESENTATIVE: Esperanza Ybarra Department of Public Health and Environment Prevention Services Division Nurse Home Visitor Program 4300 Cherry Creek Drive South Denver, CO 80127 CONTRACTOR Board of County Commissioners of Eagle County 500 Broadway Eagle, Colorado 91631 For the use and benefit of the Eagle County Health & Human Services 551 Broadway Eagle, Colorado 81631 CONTRACTOR ENTITY TYPE. Colorado Political Subdivision CONTRACTOR FEIN OR SOCIAL SECURITY NUMBER BILLING STATEMENTS RECEIVED: Monthly STATUTORY AUTHORITY. Section 25-31-101, et sep•, C.R.S., as amended CONTRACT PRICE NOT TO EXCEED $304,116.00.00 FEDERAL FUNDING DOLLARS: $ STATE FUNDING DOLLARS $304,116.00 MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR FY 09: $304,116.00 CONTRACTOR REPRESENTATIVE: Jennie Wahrer Eagle County Health & Htunan Services 551 Broadway Eagle, Colorado 81631 SCOPE OF WORK: Contractor is to provide nurse home visitor services to low-income, first-time mothers in the state of Colorado. Page 1 of 4 EXHIffiTS: The following exhibits are hereby incorporated: Exhibit A - Additional Provisions (and its attachments if any - e.g., A-1, A-2, etc.) Exhibit B - Statement of Work and Budget (and its attachments if any - e.g., B-1, B-2, etc.) Exhibit C - Limited Amendment Template for Task Orders Exhibit D - Medicaid Reimbursement Guidelines Exhibit E - Sample Funding Letter GENERAL PROVISIONS The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task Order Contract provide more specificity than these general clauses, the more specific provision shall control. This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract including, but not limited to, Exhibit One thereto. The total term of this Task Order Contract, including any renewals or extensions, may not exceed five (5) years. The parties intend and agree that all work shall be performed according to the standards, terms and conditions set forth in the Master Contract. In accordance with section 24-30-202(1), C.R.S., as amended, this Task Order Contract is not valid until it has been approved by the State Controller, or an authorized delegee thereof. The Contractor is not authorized to, and shall not; commence performance under this Task Order Contract until this Task Order Contract has been approved by the State Controller or delegee. The State shall have no fmancial obligation to the Contractor whatsoever for any work or services or, any costs or expenses, incurred by the Contractor prior to the effective date of this Task Order Contract. If the State Controller approves this Task Order Contract on or before its proposed effective date, then the Contractor shall commence performance under this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order Contract after its proposed effective date, then the Contractor shall only commence performance under this Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through and including the date specified on page one of this Task Order Contract, unless sooner terminated by the parties pursuant to the terms and conditions of this Task Order Contract and/or the Master Contract. Contractor's commencement of performance under this Task Order Contract shall be deemed acceptance of the terms and conditions of this Task Order Contract. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made apart hereof as if fully set forth herein. Unless otherwise stated, all exhibits and/or attachments to this Task Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated, the terms of this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event of conflicts or inconsistencies between the Master Contract and this Task Order Contract (including its exhibits and/or attachments), or between this Task Order Contract and its exhibits and/or attachments, such conflicts or inconsistencies shall be resolved by reference to the documents in the following order of priority: 1) the Special Provisions of the Master Contract; 2) the Master Contract (other than the Special Provisions) and its exhibits and attachments in the order specified in the Master Contract; 3) this Task Order Contract; 5) the Page2of4 Additional Provisions -_Exhibit A, and its attachments if included, to this Task Order Contract; 4) the Scope/Statement of Work -Exhibit B, and its attachments if included, to this Task Order Contract; 6) other exhibits/attachments to this Task Order Contract in their order of appearance. 4. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order Contract, shall perform and complete, in a timely and satisfactory manner, all work items described in the Statement of Work and Budget, which are incorporated herein by this reference, made a part hereof and attached hereto as "Exhibit B". 5. The State, with the concurrence of the Contractor, may, among other things, prospectively renew or extend the term of this Task Order Contract, subject to the limitations set forth in the Master Contract, increase or decrease the amount payable under this Task Order Contract, or add to, delete from, and/or modify this Task Order Contract's Statement of Work through a "Limited Amendment for Task Orders" that is substantially similar to the sample form Limited Amendment that is incorporated herein by this reference and identified as Exhibit C. To be effective, this Limited Amendment must be signed by the State and the Contractor, and be approved by the State Controller or an authorized delegate thereof. Upon proper execution and approval, this Limited Amendment shall become a formal amendment to this Task Order Contract. This contract is subject to such modifications as may be required by changes in Federal or State law, or their implementing regulations. Any such required modification shall automatically be incorporated into and be part of this Task Order Contract on the effective date of such change as if fully set forth herein. 6. The conditions, provisions, and terms of any RFP attached hereto, if applicable, establish the minimum standards of performance that the Contractor must meet under this Task Order Contract. If the Contractor's Proposal, if attached hereto, or any attachments or exhibits thereto, or the Scope/Statement of Work - Exhibit B, establishes or creates standards of performance greater than those set forth in the RFP, then the Contractor shall also meet those standards of performance under this Task Order Contract. Page 3 of 4 IN WITNESS WHEREOF, the State has executed this Task Order Contract as of the day first above written. * Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's behalf and acknowledge that the State is relying on their representations to that effect and accept personal responsibility for any and all damages the State may incur for any errors in such representation. CONTRACTOR STATE OF COLORADO: Board of County Commissioners of Eagle County, BILL BITTER, JR. GOVERNOR for the use and benefit of the Eagle County Health & Human Services (apolitical subdivision of the _ state of Colorado) Legal Name of Contracting Entity By For Executive Director Department of Public Health and Environment - r'- < ___.- r,~ - Department Program Approval: Signature of Authorized Officer ~P~i"tr' ~'• ~Y1V Of'l~_~(7~i(7~ f IMF BY Print Name & Title of Au~thonzed Officer 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. STATE CONTROLLER: David J. McDermott, CPA By Date Page 4 of 4 EXHIBIT A ADDITIONAL PROVISIONS To Task Order Contract Dated 04/21/08 -Contract Routing Number 09 FLA 00003 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. 1. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Determination. The State has determined that this Task Order Contract does not constitute a Business Associate relationship under HIPAA. 2. This Task Order Contract is governed by those rules that were adopted by the state of Colorado's Board of Health pursuant to section 25-31-104, C.R.S., as amended, incorporated herein by reference. To receive compensation under this Task Order Contract, the Contractor shall submit a signed Monthly Cost Reimbursement Statement in a format acceptable to the State. A sample Cost Reimbursement Statement is attached hereto as Attachment A-1 and incorporated herein by this reference. A Cost Reimbursement Statement must be submitted within sixty (60) calendar days of the end of the billing period for which services were rendered. Expenditures shall be in accordance with the Statement of Work attached hereto as Exhibit B. These items may include, but are not limited to, the Contractor's salaries, fringe benefits, supplies, travel, operating, indirect costs which are allowable, and other allocable expenses related to its performance under this Task Order Contract. Cost Reimbursement Statements shall: 1) reference this Task Order Contract by its contract routing number, which number is located on page one of this Task Order Contract; 2) state the applicable performance dates; 3) state the names of payees; 4) include a brief description of the services performed during the relevant performance dates; 5) describe the incurred expenditures if reimbursement is allowed and requested; 6) show the total amount of local match dollars; and, 7) show the total requested payment. Payment during the initial, and any renewal or extension, term of this Task Order Contract shall be conditioned upon affirmation by the State that all services were rendered by the Contractor in accordance with the terms of this Task Order Contract. Cost Reimbursement Statements shall be sent to: Esperanza Ybarra Prevention Services Division Nurse Home Visiting Program Colorado Department of Public Health and Environment PSD - WH - A4 4300 Cherry Creek Drive South Denver, CO 80246 To be considered for payment, billings for payments pursuant to this Task Order Contract must be received within a reasonable time after the period for which payment is requested, but in no event no later than sixty (60) calendar days after the relevant performance period has passed. Final billings under this Task Order Contract must be received by the State within a reasonable time after the expiration or termination of this Task Order Contract; but in no event no later than sixty (60) calendar days from the effective expiration or termination date of this Task Order Contract. Unless otherwise provided for in this Task Order Contract, "Local Match", if any, shall be included on all billing statements as required by the funding source. The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless approved in writing by the appropriate federal agency. To be attached to CDPHE Page 1 of 3 Revised: 12/19/06 Task Order v1.0 (11/OS) contract template EXHIBIT A 4. The Contractor is authorized to make limited transfers of funds from one line item in its Budget to another line item in its Budget with the prior, expressed, written consent of the State. A transfer from one line item to another line item may not exceed ten percent (10%) of the total amount of the line item from which the transfer is made. If the Contractor desires to transfer more than ten percent (10%) from one line item in its Budget to another line item in its Budget, then the Contractor shall prior to the transfer, enter into an amendment to the Original Task Order Contract with the State, which requires State Controller or delegate approval, before the transfer can be made. 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 Contract, the Contractor certifies that the Contractor shall comply with the requirements of the Act and shall 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 shall 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. The Contractor certifies, to the best of its knowledge and belief, that no federally appropriated funds have been paid or shall 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 Contract, and the extension, continuation, renewal, amendment, or modification of this Task Order Contract, or any grant, loan, or other cooperative agreement that utilizes Federal funds. If any funds other than federally appropriated funds have been paid or shall 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 Contract, 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. Notwithstanding anything herein to the contrary, the parties understand and agree that all terms and conditions of this Task Order Contract and the exhibits and attachments hereto which may require continued performance, compliance or effect beyond the termination date of this Task Order Contract shall survive such termination date and shall be enforceable by the State as provided herein in the event of such failure to perform or comply by the Contractor. To be attached to CDPHE Page 2 of 3 Revised: 12/19/06 Task Order v1.0 (11/OS) contract template EXHIBIT A The Contractor shall protect the confidentiality of all applicant or recipient records and other materials that are maintained in accordance with this Task Order Contract. Except for purposes directly connected with the administration of this Task Order Contract, 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. 10. Under this Task Order Contract, the Contractor may 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 may be provided with information about programs such as Prenatal Plus, WIC, etc., as needed. The Contractor may provide all individuals seeking reproductive health services: with information about pregnancy planning, the consequences of unintended pregnancies, and, referrals to comprehensive family planning services. 11. 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 actively 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 shall advise such clients that an interpreter shall be provided for them. If a client has their own interpreter, they shall be advised that the Contractor shall provide an interpreter if the client so chooses. To be attached to CDPHE Page 3 of 3 Revised: 12/19/06 Task Order v1.0 (11/OS) contract template ATTACHMENT A-1 INVOICE NUMBER TASK ORDER REIMBURSEMENT STATEMENT TO: Esperanza Ybarra Colorado Department of Public Health and Environment Prevention Services Division 4300 Cherry Creek Drive South, PSD - WH - A4 Denver, Colorado 80246-1530 FAX: ( 303 ) 782-5576 TYPE OF PROGRAM: FEDERAL ID NUMBER: FROM: DATE OF EXPENDITURE: FROM: TO: Final Bill? ^ Yes ^ No Reimbursement Description of Expenditure Local Agency Match Amount Requested Total GRAND TOTAL This is to certify that the above expenses were incurred per Contract # and we are requesting reimbursement for same. SIGNATURE (CONTRACTOR): DATE: I hereby certify that all contract requirements have been met and the amounts are correct. Payment is authorized. AUTHORIZED DESIGNEE (STATE): DATE: Contractor Notified of Reimbursement Amount ChangeY G Yes G No Initial: EXHIBIT B STATEMENT OF WORK To Task Order Contract Dated 04/21/08 -Contract Routing Number 09 FLA 00003 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified above. 1. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task •Order Contract, shall perform and complete, in a timely and satisfactory manner, all activities and services related to the Colorado Nurse Home Visitor Program (NHVP). 2. The Contractor shall coordinate its efforts with the state's NHVP Director, the University of Colorado at Denver and Health Sciences Center (UCDHSC), National Center for Children, Families and Communities (National Center), and/or subcontractors of the National Center including but not limited to the Nurse-Family Partnership National Service Office (NFPNSO) and Invest in Kids (IIK). 3. The Contractor shall perform and complete all activities related to the NHVP. The services provided by the contractor must be deemed acceptable, in good faith, by the state. For a service to be "acceptable" it must comply with all, but not limited to, the items listed below, which are incorporated and made part hereof by reference. These documents are located at: httR//www cdphe state co us/mss/nursehome/index.html • Colorado Nurse Home Visitor Program Act, as described in § 25-31-101, C.R.S. • Rules Concerning the Nurse Home Visitor Program NHVP Fiscal and Programmatic Processes and Procedures • NHVP Audit Recommendations (as applicable) • NHVP Grantee Caseload Guidelines • Nurse-Family Partnership Implementation Agreement: 4. The Contractor shall provide the nurse home visitor services in accordance with the FY2008-09 Final Approved Budget, attached as Attachment B-1. 5. The Contractor shall complete the NFPNSO training in the following sequence: (1) Training I ("Pregnancy"), (2) Training II ("Infancy", and (3) Training III ("Toddler'). T'he contractor must also attend all nurse supervisor training as required. The contractor must ensure that at least one staff member receives the Nursing Child Assessment Satellite Training (NCAST). The contractor is responsible for scheduling and payment of the training. 6. The Contractor will be required to participate in meetings or trainings as requested by the CDPHE, IIK and NFPNSO. The contractor, as applicable, must cover all trainings costs. 7. The Contractor shall submit, but not limited to, the following reports, incorporated by reference. These documents with corresponding due dates are located at: http~//www cdphe state co us/as/nursehome/index.html: • Expenditure Year-to-Date Report • Mid-Year Budget Projections Report Final Expenditure Report • annual progress report (otherwise known as the NHVP Continuation Application) 8. The Contractor shall collect data for evaluation purposes, using forms developed by the National Center and/or its subcontractors. Enter the data collected into the Clinical Information System (CIS) program, on a monthly basis; taking 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 (HIl'AA) regulations, including, but not limited to, authorizations, data use agreements, business Page 1 of 2 EXHIBIT B associate agreements, as necessary. Contractor's failure to comply with any applicable provision of HIPAA will constitute a breach of this agreement. 9. The Contractor shall provide the equipment and supplies needed for Program implementation. 10. The Contractor shall ensure that program eligibility is based on the client's income and should not be restricted by age or length of gestation and that all program brochures and referral materials are stated as such. 11. The Contractor shall utilize a standard, linguistically appropriate program application in which clients document their income or attest that they receive no income as a means of verifying program eligibility. Client income documentation must be collected and maintained. 12. During FY2008-09, the Contractor is not required, but may choose to submit Medicaid reimbursement requests to the Colorado Department of Health Care Policy and Finance (HCPF) for all eligible clients in accordance with HCPF procedures and the Medicaid Reimbursement Guidelines, which is incorporated herein by this reference, made a part hereof, and attached hereto as Exhibit D. 13. If funded for FY2009-10 and every year thereafter, the Contractor shall submit Medicaid reimbursement requests for all eligible clients in accordance with HCPF procedures and the Medicaid Reimbursement Guidelines attached hereto as Exhibit D. 14. Funding adjustments may be made during the term of this contract. Grant awards are made using NHVP funding and Medicaid reimbursement estimates. The total amount of funding for the term of this contract may not exceed the Total Project Cost Request from CDPHE as stated in the FY2008-09 Final Approved Budget, attached as Attachment B-1. If the contractor draws more Medicaid funding, the state will reduce the NHVP funding. Unless otherwise approved, overages of Medicaid funding in one fiscal year are reconciled in the subsequent fiscal year. If the contractor draws less Medicaid funding the state will increase the NHVP funding, if funding is available, during the Mid-Year Budget Projections process. The state makes funding adjustments on this contract using a Funding Letter substantially equivalent to Exhibit E and bearing the approval of the State Controller or his designee. The funding letter shall not be deemed valid until it shall have been approved by the State Controller or his designee. 15. The Contractor shall provide the state's NHVP administrators and program consultants with reasonable access to its operations to perform: periodic site reviews, data reviews, fiscal reviews or other evaluations of the contractor's NHVP program. The contractor shall cooperate during all periodic site visits, data reviews, fiscal reviews and other evaluations or audits conducted by the State. 16. Notwithstanding anything in this contract to the contrary, the parties understand and agree that all terms and conditions of this contract which may require continued performance, compliance, or effect beyond the termination date of the contract and shall survive such termination date and shall be enforceable by the State as provided herein in the event of failure to perform or comply by the Contractor. Page 2 of 2 COLORADO NURSE HOME VISITOR PROGRAM Attachment B-1 NHVP Flnal Budget GRANTEE: Eagle County Heaith 8 Human 3ervites 2008-09 PROJECT. NHVP program SOURCE OF FUND3 Annual No. of Salary months TOTAL REIIIi! -~ :• AMOUNT OTHE_R80UWCL3 e , . =...~ `•#com ~ ~ ~• Rate Butl et FTE REQUIRED -' ~ - PERSONAL SERVICES Personal Seances Nurse Supervisor 74,380 12 O S 37,190 0 37,190 Nurse Home Viskor 1 84,000 12 1 84,000 0 64,000 Nurse Home Visdor 2 84,000 12 1 84,000 0 84,000 Data Entry Person 33,300 12 0,25 8,325 0 8,325 ContmcluaVFee br SeMce(translator) 33,300 8 05 11,100 0 11,100 SupeMSing Personnel 84,000 12 0.05 4,200 4,200 0 Fnnge Benefks Rate = 49% 172,980 55% 95,128 2,058 93,070 1. TOTAL PERSONAL SERVICES 289 ~•~ 8 ~•~ 277 ~•~ OPERATNG Detail Ez nses Office Supplies $380/nursetyear $1,080 $1,080 $1,080 Cliem Support Matenals $50/family/year $2,500 $2,500 $2,500 Copies of brtns/faalkators $40/family/year $2,000 52,000 $2,000 Postage 58/family/year $300 $300 $300 Computer Network Fees $30/month $380 $380 $380 Cellular Usage Fees 900/nurse/year $2,700 $2,700 $2,700 Medlaal 8 Program Suppies $400/NHV . _ - - Professional Development $500lnurse/year $1,500 $1,500 $1,500 2. TOTAL OPERATNG 512040 00 .00 11 240 00 EQUPMENT Detail Ex uses Computers w/ Software 1500/per nurse $3,000 $3,000 $3,000 $0 Cellular Phones $75/phonelnurse $225 $225 $225 $D 9. TOTAL EQUPMENT $3 225 00 $3 225 00 $0 00 TRAVEL Detail Ex ses Visk Outreach Mileage $8,823 $8,823 NFP Training Travel 3 x mle, perdiem, hotel $3,080 $3,080 $0 NCAST Travel see nanahve $800 $800 $0 PIPE Travel $300 $300 $0 Nurse Meatirrgs supv/other $300 $300 4. TOTAL TRAVEL 511 103.00 $3 980.00 $7 123 00 NFP TRAINING 8 TECH ASSISTANCE Detail Ex nses Technical Assistance $8.088 $8,068 On~omg Nurse Educehon 2nd 8 3b year ony $0 $D Inkial Nurse EduaHion $3015/NHV $7,230 $7,230 $D Inklal Superwsor Educatan 4287/Supv 51,267 $4,287 ~ Educetron Matenals $459/nurse 8 Supv $1,377 $1,377 $0 6. TOTAL TRANING 8 TECH ASSISTANCE $20 942.00 $12 874 00 $8 068.00 NCAST COSTS Detail NCAST Trainin BMatedals NCAST Registratron see nartahve $2,370 $2,370 $D NCAST Malenals see narrative $1,282 $1,282 $0 PIPE TraimnQ Matenals see nartatlve $900 $900 $D 6. TOTAL NCAST COSTS $4 552 00 $4 552 00 $0 00 OTHER COSTS Detail OtherPro nm Costs Progam Development Fae one lime (81 Stan-up $3,724 $3,724 $0 NFP Data 8 Reporting Fee one tmle ~ start-up $1,304 $1,304 $0 7. TOTAL OTHER C06T8 $5 028.00 $5 028.00 $0.00 TOTAL DIRECT PROGRAM COSTS Add Lines 7-7 S SS3.00 $36 817.00 $S 116.00 ADMINSTRATNE COSTS Detail Adminstraave Costs flscal manangmem. payroll, autla, MadreaW billing for NHVP seraes ony 3200 3200 0 Olfice fumkure 2500 2500 0 (Phones 8 phone system 1500 1500 0 1 county vehlde 24000 24000 0 TOTAL ADMINISTRATIVE COSTS $31 2()0.00 $31 2(10.00 $0.00 TOTAL PROJECT COST (Direct Program +Adminlstrative Costs) $372 083.00 $67117.00 $304116.00 LIST OTHER SOURCES of FUNDING ru.n orinxewl MEDICAID $ descnbed m bud et Ea b Coun 537.458 00 desarbetl In bud et B hlStart $29.859 00 Inkind book ba Leers P ram $1 250 00 Inkind Wane Welcome 8 Mown On Rs B ht rnnm 5 5750 00 ' TOTAL OTHER SOURCES $68,117.00 Signature of Authonmd Reoresentatue Date Ft'OBOa F I eutlBM NprY/0,3008 EXHIBIT C DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT (ADD PROGRAM NAME HERE) DEPARTMENT OR AGENCY NUMBER *** CONTRACT ROUTING NUMBER **_***** ELIMINATE ALL INFORMATION APPEARING IN RED LIMITED AMENDMENT FOR TASK ORDERS #* This Limited Amendment is made this **** day of *********, 200*, by and between the State of Colorado, acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT, whose address or principal place of business is 4300 Cherry Creek Drive South. Denver, Colorado 80246, hereinafter referred to as the "State"; and, LEGAL NAME OF ENTITY, (legal type of entity), whose address or principal place of business is Street Address, City, State & Zip Code, hereinafter referred to as the "Contractor". FACTUAL RECITALS The parties entered into a Master Contract, dated * * * * * * * * * *, * * * *, with contract routing number ** *** ***** "the Master Contract"). Pursuant to the terms and conditions of the Master Contract, the parties entered into a Task Order Contract, dated ******** **, ****, with contract encumbrance number PO *** ********** and contract routing number ** *** *****, [insert the following if previous amendment(s), change order(s), renewal(s) have been processed: as amended by] [include all previous amendment(s), change order(s), renewal(s) and their routing numbers], [insert the following if previous amendment(s), change order(s), renewal(s) have been processed: collectively] referred to herein as the "Original Task Order Contract, whereby the Contractor was to provide to the State the following: [Briefly describe what the Contractor was to do under the Original Task Order Contract -indent this paragraph] [Please choose one of the following four options and delete the other three options not selected] The State promises to [choose one and delete the other] increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars, ($*.**) during the current term of the Original Task Order Contract in exchange for the promise of the Contractor to perform the [choose one and delete the other] increased/decreased work under the Original Task Order Contract. Page 1 of 5 EXHIBIT C The State promises to pay the Contractor the sum of ********** Dollars, $( *.**) in exchange for the promise of the Contractor to continue to perform the work identified in the Original Task Order Contract for the renewal term of **** years/months, ending on ******** **, ****. The State promises to [choose one and delete the other] increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars, $( *.**1 for the renewal term of **** [choose one and delete the other] years/months, ending on ******** **, ****, in exchange for the promise of the Contractor to perform the (choose one and delete the other] increased/decreased work described herein. The State hereby exercises a "no cost" change to the [choose those that apply and delete those that don't apply] budget, specifications within the Statement of Work, project management/manager identification, notice address or notification personnel, or performance period within the [choose one and delete the other] current term of the Original Task Order Contract or renewal term of the Original Task Order Contract. NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: 1. Consideration for this Limited Amendment to the Original Task Order Contract consists of the payments and services that shall be made pursuant to this Limited Amendment, and promises and agreements herein set forth. 2. It is expressly agreed to by the parties that this Limited Amendment is supplemental to the Original Task Order Contract, contract routing number ** *** *****, [insert the following language here if previous amendment(s), change order(s), renewal(s) have been processed] as amended by [include all previous amendment(s), change order(s), renewal(s) and their routing numbers], [insert the following word if previous amendment(s), change order(s), renewal(s) have been processed, otherwise delete "collectively"]collectively referred to herein as the Original Contract, which is by this reference incorporated herein. All terms, conditions, and provisions thereof, unless specifically modified herein, are to apply to this Limited Amendment as though they were expressly rewritten, incorporated, and included herein. 3. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified, altered, and changed in the following respects only: [Please choose one of the following three options and delete the two options not selected] A. [Use this paragraph when changes to the funding level of the Original Task Order Contract occur during the current term of the Original Task Order Contract] This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment is for the current term of ********* **, Page 2 of 5 EXHIBIT C ****, through and including ********* **, ****. The maximum amount payable by the State for the work to be performed by the Contractor during this current term is [choose one and delete the other] increased/decreased by ********** Dollars, $( *.**1 for an amended total financial obligation of the State of ********** DOLLARS, $*.** . [Delete the following sentence if not applicable in your situation] The revised Statement of Work is incorporated herein by this reference and identified as "Attachment *". [Delete the following sentence if not applicable in your situation] The revised Budget is incorporated herein by this reference and identified as "Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. [Use this paragraph when the Original Task Order Contract will be renewed for another term] This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment is for the renewal term of ********* **, ****, through and including ********* **, ****. The maximum amount payable by the State for the work to be performed by the Contractor during this renewal term is ********** Dollars, $( *.**1 for an amended total financial obligation of the State of ********** DOLLARS, ($*.**1. [Delete the following sentence if not applicable in your situation] The revised Statement of Work is incorporated herein by this reference and identified as "Attachment *". [Delete the following sentence if not applicable in your situation] The revised Budget is incorporated herein by this reference and identified as "Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. [Use this paragraph when there are "no cost changes" to the Budget, the specifications within the original Statement of Work, allowable contract provisions as noted, or performance period.] This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment [choose those that apply and delete those that don't] modifies the Budget in [identify location in contract], modifies the Statement of Work in [identify location in contract], modifies the project management/manager identification in [identify location in contract], modifies the notice address or notification personnel in [identify location in contract], modifies the period of performance in [identify location in contract] of the Original Task Order Contract. The revised [choose those that apply and delete those that don't] Budget, Statement of Work, project management/manager identification, notice address or notification personnel, or period of performance is incorporated by this reference and identified as. All other terms and conditions of the Original Task Order Contract are reaffirmed. 4. The effective date of this Limited Amendment is **/**/****, or upon approval of the State Controller, or an authorized delegate thereof, whichever is later. Page 3 of 5 EXHIBIT C 5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General Provisions of the Original Task Order Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Limited Amendment and any of the terms and provisions of the Original Task Order Contract, the terms and provisions of this Limited Amendment shall in all respects supersede, govern, and control. The Special Provisions and other terms and conditions of the Master Contract shall always control over other provisions of the Original Task Order Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Master Contract concerning the absence of personal interest of state of Colorado employees and the certifications in the Special Provisions relating to illegal aliens are presently reaffirmed. 6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. Page 4 of 5 EXHIBIT C IN WITNESS WHEREOF, the parties hereto have executed this Limited Amendment on the day first above written. CONTRACTOR: STATE: [LEGAL NAME OF CONTRACTOR] (a political subdivision of the State of Colorado) By: Name• Title: HEALTH FEIN: ATTEST: Because the Contractor is a governmental entity, an attestation is required (Seal, required) By: City, City and County, County, Special District, or Town Clerk or Equivalent [Delete inapplicable language.] By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This limited amendment 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 goods and/or services provided. STATE CONTROLLER Leslie M. Shenefelt By: Date: By: STATE OF COLORADO Bill Ritter, Jr. Governor For the Executive Director DEPARTMENT OF PUBLIC AND ENVIRONMENT PROGRAM APPROVAL: Page 5 of 5 Exhibit D Colorado Department of Public Health and Environment State Fiscal Year 2008-2009 Colorado Nurse Home Visitor Program MEDICAID REIMBURSEMENT GUIDELINES Agencies receiving funding through the Colorado Nurse Home Visitor Program (NHVP) are required to bill the Colorado Department of Health Care Policy and Financing (HCPF) for Targeted Case Management (TCM) services provided to Medicaid eligible mothers and children receiving services through the NHVP. Below is the information pertaining to the NHVP Medicaid reimbursement process. Contractor Name: Eagle County Health and Human Services Reimbursement Period: July 1, 2008 To June 30, 2009 Definition of Reimbursable Services: Colorado Nurse Home Visitors will provide Targeted Case Management (TCM) services to first-time (defined as no previous Live births), pregnant women or whose first child is less than one month old and who are at or below 200% of the Federal Poverty Level. Program enrollment occurs during pregnancy, or within one month postpartum, and services are designed to continue through the child's second birthday. TCM services include: Assessment of the needs for health, mental health, social services, education, housing, child care, and related services for the women and children; Development of care plans to obtain the needed services; Referral to resources to obtain the needed services, including to medical providers who provide care to Medicaid-eligible pregnant women and children; Routine monitoring and follow-up visits with the women in which the progress in obtaining the needed services is monitored, problem-solving assistance is provided, and the care plans are revised to reflect the women and children's current needs. Mprlirairl Rillina infnrmatinn~ NHVP providers will submit bills through the Medicaid Management Billing Cycle Information System (HMIs) at the end of the month for each motherfchild receiving a visit. Claim Form CO-1500 Claim Type E (practitioner/physician) 11 (clinic), 12 (Home), 50 (Family Qualified Health Center), and 72 (Rural Place of Service Health Center) G9006, HD (For services rendered to the mother) Procedure Code Modifiers T1017, HD (For services rendered to the child) Affiliated Computer Services (ACS), the Medicaid fiscal agent, has a 120-day "timely filing" policy (invoices must be submitted to ACS within 120 days Billing Requirements from the date of service). Claims are usually paid/denied/adjustedtyithin two weeks of receipt -the maximum ACS response time is set at 30 days. For information related to Medicaid billing and training, please contact Affiliated Computer Services (ACS) at http:/lcoloradomedicaid.acs-inc.com or Medicaid Contractor Provider Services Unit at 1-800-237-0757 or (303) 534-0146 Monday through Friday, 8:00 a.m. to 5:00 p.m. ~7.._..~.._...1.... .. ,_...a.. ,.a !'+:....`_.. T__s..._ /'i ..1 ,...,..1 ._ Tl,..-....w_,...a ,_CTT,...IaL /"+...... Page 1 of 2 Exhibit D Policy and Financing, at 303-866-2693 or Ginger.Burton(c~state.co.us if you have questions on the Medicaid enrollment or billing process. Medicaid Reimbursement Rate $213.64 For the Mother -Services to the mother shall be limited to 3 units per month with a lifetime maximum of 30 units, or 3 units per month for 10 months. One (1) unit equals 15 minutes of service. Each unit will equal $71.22 ($213.64 divided by 3). Full Medicaid reimbursement will be earned with a minimum of 45 minutes of service per month. Service Limits For the Child -Services to the child shall be limited to 3 units per month with a lifetime maximum of 75 units, or 3 units per month for 25 months. One (1) unit equals 15 minutes of service. Each unit will equal $71.22 ($213.64 divided by 3). Full Medicaid reimbursement will be earned with a minimum of 45 minutes of service per month. FY2008-09 Estimated $0.00 Medicaid Revenue (Medicaid revenue is not required in the first year for newly funded agencies; however, Medicaid billing is required commencing FY2009-10 and each year thereafter.) Page 2 of 2 Exhibit E Date TO: (contractor's name here) SUBJECT: Funding Letter No. SAMPLE FUNDING LETTER State Fiscal Year: In accordance with Exhibit B, Paragraph 13 of contract routing number ,between the State of Colorado Department of Public Health and Environment, (division) and (contractor's name) covering the period of (contract start date) through (contract end date), the undersigned commits the following funds to the contract: The amount of funds available and specified in Paragraph is (increased/decreased) by (~ amount of chance) to a new total funds available of ($_~ to satisfy orders under the contract. Paragraph is hereby modified accordingly. This funding letter does not constitute an order for services under this contract. This funding letter is effective upon approval by the State Controller or such assistant as he may designate. APPROVALS: State of Colorado: Bill Ritter, Jr., Governor gy: Date: For the Executive Director Colorado Department of Public Health and Environment By: Date: _ For (Division 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 goods and/or services provided. State Controller Leslie M. Shenefelt By: Date Date Issued: February 10, 2003 Page 1 of 1