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HomeMy WebLinkAboutC24-258 CDHS Behavioral health Administration_JBBSAmendment Contract Number: 25 IBEH 188969 Page 1 of 3 Rev. 1/14/19
CONTRACT AMENDMENT #1
SIGNATURE AND COVER PAGE
State Agency
Colorado Department of Human Services
Behavioral Health Administration
Original Contract Number
24 IBEH 187666
Contractor
Eagle County Colorado for the use and benefit of
Eagle County Sheriff's Department
Amendment Contract Number
25 IBEH 188969
Current Contract Maximum Amount
Initial Term
Contract Performance Beginning Date
February 13, 2024
State Fiscal Year 2024 $40,000.00
Extension Terms Current Contract Expiration Date
June 30, 2025 State Fiscal Year 2025 $84,000.00
Total for All State Fiscal Years $124,000.00
THE PARTIES HERETO HAVE EXECUTED THIS AMENDMENT
Each person signing this Amendment represents and warrants that he or she is duly authorized to execute this Amendment
and to bind the Party authorizing his or her signature.
CONTRACTOR
Eagle County Colorado for the use and benefit of
Eagle County Sheriff's Department
______________________________________________
By: Jeff Schroll, County Manager
Date: _________________________
STATE OF COLORADO
Jared Polis, Governor
Colorado Department of Human Services
Michelle Barnes, Executive Director
______________________________________________
By: Dannette R. Smith, Commissioner, Behavioral Health
Administration
Date: _________________________
In accordance with §24-30-202 C.R.S., this Amendment is not valid until signed and dated below by the State Controller or an
authorized delegate.
STATE CONTROLLER
Robert Jaros, CPA, MBA, JD
By:___________________________________________
Toni Williamson / Telly Belton / Amanda Rios
Amendment Effective Date:_____________________
DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
6/13/2024 6/13/2024
6/14/2024
Amendment Contract Number: 25 IBEH 188969 Page 2 of 3 Rev. 1/14/19
1. PARTIES
This Amendment (the “Amendment”) to the Original Contract shown on the Signature and Cover
Page for this Amendment (the “Contract”) is entered into by and between the Contractor, and the
State.
2. TERMINOLOGY
Except as specifically modified by this Amendment, all terms used in this Amendment that are
defined in the Contract shall be construed and interpreted in accordance with the Contract.
3. AMENDMENT EFFECTIVE DATE AND TERM
A. Amendment Effective Date
This Amendment shall not be valid or enforceable until the Amendment Effective Date
shown on the Signature and Cover Page for this Amendment. The State shall not be bound
by any provision of this Amendment before that Amendment Effective Date, and shall have
no obligation to pay Contractor for any Work performed or expense incurred under this
Amendment either before or after of the Amendment term shown in §3.B of this Amendment.
B. Amendment Term
The Parties’ respective performances under this Amendment and the changes to the Contract
contained herein shall commence on the Amendment Effective Date shown on the Signature
and Cover Page for this Amendment or July 1, 2024, whichever is later and shall terminate
on the termination of the Contract.
4. PURPOSE
In accordance with the provisions of this Contract and its exhibits and attachments, the
Contractor shall provide substance abuse and mental health treatment in the Eagle
County jail.
The purpose of this amendment is to update and replace the following exhibits with the most
current version for Fiscal Year 2025 contract extension and renewal: Exhibit A,
Statement of Work, the Exhibit B, Budget, the Exhibit C, Miscellaneous Provisions, and
the Exhibit D, HIPAA BAA QSOA.
The Contract and all prior amendments thereto, if any, are modified as follows:
A. The Contract Initial Contract Expiration Date on the Contract’s Signature and Cover Page is hereby
deleted and replaced with the Current Contract Expiration Date shown on the Signature and Cover
Page for this Amendment.
B. The Contract Maximum Amount table on the Contract’s Signature and Cover Page is hereby
deleted and replaced with the Current Contract Maximum Amount table shown on the
Signature and Cover Page for this Amendment.
C. REPLACE Exhibit A, Statement of Work, with Exhibit A-1, Statement of Work, attached
and incorporated by reference.
DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
Amendment Contract Number: 25 IBEH 188969 Page 3 of 3 Rev. 1/14/19
D. ADD Exhibit B-1, Budget, attached and incorporated by reference.
E. REPLACE Exhibit C, Miscellaneous Provisions, with Exhibit C-1, Miscellaneous
Provisions, attached and incorporated by reference.
F. REPLACE Exhibit D, HIPAA BAA QSOA, with Exhibit D-1, HIPAA BAA QSOA, attached
and incorporated by reference.
5. LIMITS OF EFFECT AND ORDER OF PRECEDENCE
This Amendment is incorporated by reference into the Contract, and the Contract and all prior
amendments or other modifications to the Contract, if any, remain in full force and effect except
as specifically modified in this Amendment. Except for the Special Provisions contained in the
Contract, in the event of any conflict, inconsistency, variance, or contradiction between the
provisions of this Amendment and any of the provisions of the Contract or any prior modification
to the Contract, the provisions of this Amendment shall in all respects supersede, govern, and
control. The provisions of this Amendment shall only supersede, govern, and control over the
Special Provisions contained in the Contract to the extent that this Amendment specifically
modifies those Special Provisions.
REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK
DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
Exhibit A-1 - Statement of Work
Jail Based Behavioral Health Services (JBBS)
FY25
Definitions and Acronyms
The following list of terms shall be applied to this contract and Statement of Work, based on
the services that are provided at each respective jails:
“Agonists” Opioid agonists such as methadone or buprenorphine are therapeutic drugs
used for the management of opioid dependence. In clinical practice, they are used for
opioid agonist maintenance therapy or withdrawal management. An agonist is a drug that
activates certain receptors in the brain. Full agonist opioids activate the opioid receptors in
the brain fully resulting in the full opioid effect.
“Antagonists” An antagonist is a drug that blocks opioids by attaching to the opioid
receptors without activating them. Antagonists cause no opioid effect and block full agonist
opioids. Examples are naltrexone and naloxone.
“Behavioral Health Administration” The BHA is a new cabinet member-led agency,
housed within the Department of Human Services, designed to be the single entity
responsible for driving coordination and collaboration across state agencies to address
behavioral health needs.
“Bridges Program/Court Liaison” means an individual employed or contracted with the
State Court Administrator’s Office (SCAO) to implement and administer a program that identifies
And dedicates local behavioral health professionals as court liaisons in each judicial district.
These individuals are responsible for facilitating communication and collaboration between
judicial and behavioral health systems.
https://www.courts.state.co.us/Administration/Unit.cfm?Unit=bridges
“Case Manager” assists in the planning, coordination, monitoring, and evaluation of
services for a client with emphasis on quality of care, continuity of services, and
cost-effectiveness.
“Certified Addiction Specialist” - CAS (Formerly CAC II & III) requires a Bachelor’s
degree in a Behavioral Health specialty (Psychology, Social Work, Human Services). This
does not include Criminal Justice, Sociology or Nursing. These individuals are approved to
provide Clinical Supervision and consultation to individuals working towards CAT or CAS.
2,000 clinically supervised hours (1,000 direct clinical hours beyond the Technician). Must
pass the NCAC II exam and Jurisprudence exam.
“Certified Addition Technician” - CAT (Formerly CAC I) requires 1000 hours of clinically
supervised work hours (does not require DORA registration prior to the 1000 hours). Once
these hours are met, the individual is not able to perform duties until the CAT is officially
approved), in addition to passing the NCAC I Exam and passing the Jurisprudence Exam.
“Critical Incidents” means a critical incident is any significant event or condition that must
be reported to the Department that is of public concern and/or has jeopardized the health,
safety and/or welfare of individuals or staff.
Exhibit A-1
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“Forensic Navigators” are not case managers, clinicians, or involved in community
supervision. The Navigators act as case coordinators, working to ensure that all internal
and external stakeholders have access to up-to-date client information. In collaboration with
stakeholders, the Navigators help to ensure that services are being delivered to clients in
an appropriate and effective manner.
“GAIN” is the Global Appraisal of Individual Needs Assessment
“LAC”, or Licensed Addiction Counselor, is a behavioral health clinician who can provide
co-occurring services. Master's degree or higher in Substance Use Disorders/Addiction
and/or related counseling subjects (social work, mental health counseling, marriage &
family, psychology, medical doctor) from a regionally accredited institution of higher
learning. 3,000 clinically supervised hours (2,000 direct clinical hours). Must pass the MAC and
jurisprudence exam. Designated providers of Clinical Supervision for all levels of
certification and licensure, in the addictions profession.
“LCSW”, or Licensed Clinical Social Worker, is a social worker trained in psychotherapy
who helps individuals deal with a variety of mental health and daily living problems to
improve overall functioning.
“LMFT”, or Licensed Marriage and Family Therapist help couples and family members
manage problems within their relationships.
“LPC”, or Licensed Professional Counselor, is a person engaged in the practice of
counseling who holds a license as a licensed professional counselor issued under the
provisions of the state of Colorado.
“Long Acting Injectable (LAI)” is an injectable medication that allows for the slow release
of medicine into the blood. An LAI can last anywhere from 2-12 weeks, which helps to
control symptoms of mental illness and / or substance use.
“Memorandum of Understanding”, or MOU, means a type of agreement between two or
more parties. It expresses a convergence of will between the parties, indicating an intended
common line of action.
“Partial Agonists” Partial agonist opioids activate the opioid receptors in the brain, but to
a much lesser degree than a full agonist. Buprenorphine is an example of a partial agonist.
An antagonist is a drug that blocks opioids by attaching to the opioid receptors without
activating them.
“Regional Accountable Entity” is responsible for building networks of providers,
monitoring data and coordinating members’ physical and behavioral health care. RAEs
replace and consolidate the administrative functions of Regional Care Collaborative
Organizations (RCCOs) and Behavioral Health Organizations (BHOs).
“Screening Tools” are brief questionnaires or procedures that examine risk factors,
mental health/trauma symptoms, or both to determine whether further, more
in-depth assessment is needed on a specific area of concern, such as mental
health, trauma, brain injuries or substance use.
Exhibit A-1
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Exhibits
A: Statement of Work - the narrative description of a project's work requirement. It defines
project-specific activities, deliverables and timelines for the Contractor providing services.
B: Budget - outline of the projected cost/expenses of the project.
C: Miscellaneous Provisions - general contract provisions and requirements including
standard conditions in contracts like payment procedures, audit thresholds, and
recommended measures against contract violation.
D: HIPAA Business Associate Agreement /Qualified Service Organization Addendum
- terms detailing required compliance with HIPAA and 42 C.F.R. Part 2 privacy regulations.
PART ONE - GENERAL PROVISIONS
Article 1
General Administration
1.1 Overall Goal. The overall goal of the JBBS program is to work towards improving the
health outcomes of the individuals served.
1.2 Participation / Catchments. County Sheriff’s may develop programs either individually,
or as multiple Sheriff’s Departments (otherwise known as a catchment), submitting a
combined work plan. It is the recommendation of the BHA that each county has their own
contract. If services are provided to a catchment, the fiscal agent county (the county holding this
primary Contract with BHA) shall enter into subcontracts with its catchment county Sheriff’s
Departments. BHA reserves the right to change the fiscal agent as necessary. Subcontracts
entered into under this provision shall adhere to the requirements of Exhibit C, Miscellaneous
Provisions, Section II.
1.3 Program Administrator. The Contractor shall select a JBBS Program Administrator,
identify the positions’ roles, responsibilities and authority, and develop a management plan
that supports the JBBS Program Coordination Group. Any changes to the Program
Administrator’s’ contact information shall be communicated via email to the Behavioral
Health Administration within one business day of change to cdhs_jbbs@state.co.us
BHA prefers that a staff person from the Sheriff’s Department assume the role of Program
Administrator. The Program Administrator shall be well versed in the JBBS Program, including
contractual requirements. The Program Administrator shall also attend JBBS Quarterly
Meetings, Round Tables and Learning Communities, and shall oversee the JBBS Program and
its operations. The Program Administrator must also notify JBBS Program Manager(s) to any
change in personnel. The Sheriff’s Department is encouraged to account for this administrative
position in their budget.
1.4 JBBS Program Coordination Group. The Contractor shall develop a process for
implementing a Program Coordination Group within the facility, to guide and support the JBBS
program. The Program Coordination Group shall meet on a regular and continual basis to
ensure project implementation and goals are progressing. In addition to monthly check-ins, the
JBBS Program Manager(s) will be available to attend periodic program coordination group
Exhibit A-1
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meetings for technical assistance, contract management, and support based on agency needs.
BHA reserves the right to record JBBS meetings as necessary.
The Program Coordination Group shall:
a. Oversee program implementation
b. Make training recommendations
c. Measure the program’s progress toward achieving stated goals, using data
provided by BHA program manager(s) to guide work
d. Ensure program effectiveness and performance is measured by specific client-centered
health outcomes and reflected in the data collected
e. Resolve ongoing challenges to program effectiveness
f. Inform agency leaders and other policymakers of program costs, developments,
and progress
g. Develop policies and protocols to ensure clinical staff have the resources and
support required for service provision
h. For JBBS Programs serving a catchment of counties, a Sheriff’s Department
representative from each county is required to participate in the JBBS Program
Coordination Group
i. Ensure the needs of all the jails in the catchment are being met by the resources
and subcontracted service providers.
1.5 Subcontractors. The JBBS Program requires a subcontract or an MOU be in place for
any and all subcontractors. See Exhibit C, Miscellaneous Provisions, Section II for
requirements regarding the use of subcontractors.
1.6 Audits. As a participant in the JBBS program, participation in regular audits may be
required. Clinical and financial documentation shall be made available when requested for
onsite or virtual review by the Behavioral Health Administration, in addition to the location(s)
where treatment services are being provided.
1.7 Recovery Support Services. SAMHSA (Substance Abuse and Mental Health Services
Administration) encourages those involved in substance abuse and / or mental health
treatment, to address their emotional, spiritual, intellectual, physical, environmental,
financial, occupational, and social needs. JBBS programs may provide recovery support
services for wraparound resources including, but not limited to, clothes, transportation,
food, emergency housing/motel vouchers, or basic hygiene purchases that will assist in
stabilizing the individual in the community.
1.8 Cultural Competency. The Contractor shall provide culturally competent and
appropriate services, per National Standards for Culturally and Linguistically Appropriate
Services (CLAS Standards), available at https://thinkculturalhealth.hhs.gov/clas/standards
The Contractor shall also make reasonable accommodations to meet the needs of
Individuals who are physically challenged, deaf or hearing impaired, or blind.
1.9 Medication Consistency. Contractor is encouraged, though not required, to participate in
the Minnesota Multistate Contracting Alliance for Pharmacy Cooperative Purchasing Agreement
to purchase medication and to utilize the Medication Consistency formulary developed by CDHS
and HCPF. If requested by the BHA, Contractor shall provide a copy of the medication formulary
available at Contractor’s jail. A copy of the CDHS and HCPF formulary is available
Exhibit A-1
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on the HCPF Website at https://hcpf.colorado.gov/pharmacy-resources. Contractor shall not bill
inmates for appointments or medications otherwise covered by JBBS. See Exhibit B, Budget
and Rate Schedule for a list of covered medications.
1.10 JBBS Crisis Intervention It is allowable for JBBS providers, while working in the jail
during their shift to support therapeutic mental health interventions (including crisis services)
when they occur. This should not interfere with current JBBS services that are actively being
administered, but in the event that an individual is experiencing a crisis.
Article 2
Confidentiality and HIPAA / 42 CFR Part Two
2.1 HIPAA Business Associate Addendum / Qualified Service Organization
Addendum. The Contractor shall agree to comply with the terms of the HIPAA Business
Associate Addendum / Qualified Service Organization Addendum, Exhibit D of this
Contract.
2.2 Third Parties and Business Associate Addendum / Qualified Service Organization
Addendum.
a. The Contractor shall require that any third parties, including subcontractors or other partner
agencies, that it involves for work to be done pursuant to this Contract agree to the most recent
CDHS version of the HIPAA Business Associate Addendum / Qualified Service Organization
Addendum, found in Exhibit D of this Contract.
b. A HIPAA Business Associate Addendum / Qualified Service Organization
Addendum is required between subcontracted treatment provider agencies for any
program that has more than one treatment subcontractor agency rendering services
in the jail in order to share assessments and screenings between subcontracted
treatment provider agencies.
2.3 Information Sharing. For the sole purpose of ensuring medication consistency for persons
with mental health disorders involved in the criminal justice system, for individuals participating
in the JBBS program, Contractor shall share patient-specific mental health health and treatment
information with all subcontractors, clinicians, and providers involved in the individual's plan of
care. All such information sharing must comply with confidentiality requirements, including
any necessary memorandums of understanding between providers, set for in the
federal “Health Insurance Portability and Accountability Act of 1996”, 45 CFR Parts
2, 160, 162, and 164.
2.4 Additional Measures. The Contractor shall agree to the following additional privacy
measures:
a. Safeguards. The Contractor shall take appropriate administrative, technical and
physical safeguards to protect the data from any unauthorized use or disclosure not
provided for in this agreement.
b. Confidentiality. The Contractor shall protect data and information according to
acceptable standards and no less rigorously than they protect their own confidential
information. The Contractor shall ensure that individual level identifiable data or
Protected Health Information (PHI) shall not be reported or made public. The
Exhibit A-1
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Contractor shall ensure that all persons (e.g., interns, subcontractors, staff, and consultants)
who have access to confidential information sign a confidentiality agreement. It is recommended
that each participating jail have a universal release of information (ROI) for JBBS clients to sign
to ensure appropriate continuity of care.
Article 3
Financial Provisions
3.1 Cost Reimbursement / Allowable Expenses. This contract is paid by cost reimbursement.
See Exhibit B, Budget and Rate Schedule, for a list of reimbursable expenses. The Rate
Schedule is non-exhaustive; other items expensed to this Contract must be reasonable toward
completion of the contract terms, are reviewable by BHA, and shall not exceed any detail in the
budget in this regard. Documentation of all monthly expenses is required to be submitted along
with the invoice each month.
3.2 Staff Time Tracking and Invoicing. The Contractor shall ensure expenses and staff
are tracked and invoiced separately for each program or funding stream. Any other funding
sources or in kind contributions supporting the JBBS Program shall be disclosed in the
invoice submission. Invoices will be submitted to cdhs_BHApayment@state.co.us
by the 20th of the following month.
3.3 Procurement Card. BHA recommends, although does not require, counties to consider
the use of a procurement card to be used for expenses related to the JBBS program.
Contractor shall follow its county’s internal guidance and policies for use of procurement
Cards.
3.4 Proportional Reduction of Funds. The Behavioral Health Administration has the
unilateral authority to proportionately reduce the contract budget amount to match current
spending rates. If the Sheriff's Department has not spent 40% of the contract budgeted
amount by November 30th, the Behavioral Health Administration may proportionately
reduce the contract budget amount to match current spending rates. If the Sheriff's
Department has not spent 65% of the contract budgeted amount by February 28th, the
Behavioral Health Administration may again proportionately reduce the contract budget
amount to match current spending rates.
3.5 Fiscal Agent County Responsibilities. Where a county is acting as a fiscal agent for
other counties, the fiscal agent county shall pay invoices received by the catchment counties
within 45 days of receipt.
3.6 Other Financial Provisions, including invoicing instructions can be found in Exhibit C,
Miscellaneous Provisions.
PART TWO - SUBSTANCE USE DISORDER (SUD) TREATMENT SERVICES
Article 1
Purpose and Target Population
1.1 Purpose. The goal of the Jail Based Behavioral Health Services (JBBS) Program is to
support County Sheriff’s in providing screening, assessment and treatment for offenders with
Exhibit A-1
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substance use disorders (SUD) and co-occurring substance use and mental health disorders,
as well as transition case management services. Through funds authorized by the Colorado
General Assembly (SB 12-163), the Behavioral Health Administration (BHA) intends to continue
funding the Jail Based Behavioral Health Services Programs as set forth in this Contract.
1.2 Target Population. Adults 18 years of age and older that are residing in the county jail
with substance use disorder or co-occurring substance use and mental health disorders. In
this regard, the Contractor, in accordance with the terms and conditions of this Contract,
shall develop, maintain, and provide behavioral health services in the county jails for
individuals highlighted in section 1.2. The Contractor, in providing required services
hereunder, shall utilize and maintain a partnership with community provider(s)/individuals
that are licensed, who are in good standing with the Department of Regulatory Agencies
(DORA), have the ability to provide services within the jail or through televideo options, and
have the capacity to provide free or low cost services in the community to inmates upon release.
Article 2
Activities and Services
2.1. Licensed Substance Use Disorder Treatment Requirements.
a. Eligible individuals must have a substance use disorder and/or a co-occurring mental health
disorder (determined by SUD and MH screening) to be eligible to receive services under the
JBBS program.
b. Individual treatment providers must hold a Substance Use Disorder Provider license and be
in good standing with the Colorado Department of Regulatory Agencies (DORA).
c. Contractor shall implement policies and procedures on how the subcontracted treatment
provider(s) will manage and maintain clinical records for the individuals served at the outpatient
community location. The providers must follow the same protocols and policies for record
management for services offered in the jail.
d. Contractor shall provide appropriate screening(s), assessment(a), brief intervention and
linkage to care in the community, based on an individualized treatment and/or transition plan.
e. Each individual’s treatment / transition plan shall incorporate:
i. Summary of the continuum of services offered to individuals based on evidence based
curricula.
ii. Frequency and duration of services offered.
iii. Description of how services are divided if an individual's treatment will be provided by
more than one treatment provider/agency.
iv. The individual’s natural communities, family support, and pro-social support.
Article 3
Standards & Requirements
3.1 Authorizing Legislation and Description of Services. The Jail Based Behavioral
Health Services (JBBS) Program is funded through the Correctional Treatment Cash Fund
Exhibit A-1
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legislated in the passage of Senate Bill 12-163. Section 18-19-103 (c), C.R.S. directs the judicial
department, the Department of Corrections, the state board of parole, the Division of Criminal
Justice of the Department of Public Safety, and the Department of Human Services to
cooperate in the development and implementation of the following:
a. Alcohol and drug screening, assessment, and evaluation.
b. Alcohol and drug testing.
c. Treatment for assessed substance abuse and co-occurring disorders.
d. Recovery support services.
The Correctional Treatment Fund Board has determined the Jail Based Behavioral Health
Services (JBBS) Program meets the requirements set forth in SB 12-163.
3.2 Level of Program Care. Services offered by the Contractor hereunder shall meet
ASAM Level 1.
Article 4
Data Reporting
4.1 Contractor is required to report information in the BHA Jail Based Behavioral Health
Services (JBBS) CiviCore Database or another database as prescribed by BHA. Data must
reflect current individual enrollment and services provided by the 15th day of each calendar
month to allow BHA staff to utilize current data. The following data elements will be captured in
the Civicore JBBS database or other database as prescribed by BHA:
a. A record for each individual who screened “positive” for a mental health disorder or substance
use disorder; other screenings completed and results thereof.
b. Basic demographic and working diagnosis information (including veteran status and
pregnancy status, if applicable).
c. The type and dosage of medications provided for Medication Assisted Treatment (MAT).
Please see Exhibit B for allowable medications.
d. Number of individuals who successfully transition to community based services upon release.
e. Program discharge outcomes and treatment status in the community after discharge.
4.2 The Contractor agrees to respond to BHA’s inquiries about data submissions within two (2)
business days and work with BHA to quickly resolve any data issue. The Contractor is required
to notify BHA of any staffing changes within 48 hours, as this individual's database access will
need to be deactivated.
Article 5
Performance Measures
5.1 Performance Measures.
a. Transition Tracking Outcomes. The goal of the JBBS program is to identify treatment service
needs and assist with engagement in community based treatment services upon release.
Contractor shall make reasonable efforts to contact all JBBS individuals who are successfully
discharged from the program and released to the community at one, two, six and 12 months
post release. The individual’s treatment status shall be recorded in the CiviCore JBBS database
Exhibit A-1
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or another data system as prescribed by BHA. If a client remains engaged in treatment post-
release, JBBS may continue to provide support through the Contractor’s Recovery Support
Services section of their budget, for up to 12 months. The following are the treatment status
options:
i. Deceased – In the event of death of the individual post-release.
ii. In Treatment – Individual is engaged in community based treatment
services as recommended in the transition plan.
iii. New Crime/Regressed - Individual returned to jail for violations or
committed a new crime.
iv. Not Applicable - Individual sentenced to Department of Corrections,
Probation, Community Corrections, or treatment status not applicable at
month two, six, or 12 due to prior tracking status of Deceased, New
Crime/Regressed, or Treatment Completed.
v. Not in Treatment – Individual is reported by the community based
treatment provider as not in treatment or the individual reports to not be in
treatment services as recommended on the transition plan.
vi. Status Unknown – Individual cannot be located.
vii. Treatment Completed – Individual has completed treatment as
recommended in the transition plan.
b. Recidivism. JBBS aims to decrease the rate of reincarceration of former JBBS participants.
This approach should result in greater treatment engagement in the community and decreased
recidivism through better identification and treatment of behavioral health needs. BHA may
conduct an annual analysis of recidivism. The following will apply to this analysis:
i. JBBS participants who have received treatment services or groups will be
included in the recidivism analysis.
ii. “Recidivism” is the analysis that will be defined as re-arrest and reincarceration for a
new crime or a technical violation related to the individual's original charge.
iii. Recidivism Target. Programs will ensure that data in the JBBS Database pertaining to
the most recent complete fiscal year (July 1 - June 30) is verified and correct by the 15th
of July following the fiscal year so that the recidivism analysis may be completed by
BHA.
Article 6
Deliverables
6.1 For Deliverables under this section, please see Part 6 - JBBS Program Deliverables
PART THREE - MENTAL HEALTH TREATMENT (SB 18-250)
Article 1
Purpose & Target Population
1.1 Purpose. The Behavioral Health Administration (BHA) is committed to efforts to provide
resources to support County Sheriffs in providing screening, assessment and treatment for
mental health and substance use disorders or co-occurring disorders; as well as transition
Exhibit A-1
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case management services to people who need such services while they are in jail. The
Jail Based Behavioral Health Services (JBBS) Program has been operational since October
2011 with funding from the Correctional Treatment Cash Fund pursuant to Section
18-19-103 (5)(c)(V).
The goal of the JBBS Program is to provide appropriate behavioral health services to inmates
while supporting continuity of care within the community after release from incarceration. This
approach should result in greater treatment engagement in the community and decreased
recidivism through better identification and treatment of behavioral health needs.
In October 2012, the Correctional Treatment Board voted to fund additional Jail Based
Behavioral Health Services Programs to additional counties across the State. As of
February 2023, there are JBBS programs in 48 county jails across the State of Colorado.
In May 2018 the Colorado General Assembly passed Senate Bill 18-250, which mandated
the JBBS Program under Colorado Revised Statutes 27-60-106. Additional mental health
funding was allocated to the JBBS program to address gaps in services for mental health
disorder screening, assessment, diagnosis and treatment. Additionally, these funds may support
psychiatric prescription services and purchase of medications. Sheriff’s Departments that
currently operate JBBS programs, as well as new applicants, are eligible to request these funds.
Sheriff’s Departments may submit an individual application, or they may submit a combined
application if they would like to apply in conjunction with other BHCounty Sheriff’s Departments.
To carry out the JBBS program, Sheriff’s Departments may partner with local community
provider(s) who can demonstrate the ability to provide services within the jail, and the
capacity to provide or link individuals released from jail to free or low cost services in the
community.
1.2 Target Population. Adults 18 years of age and older that are residing in the county jail
with substance use disorder or co-occurring substance use and mental health disorders. In
this regard, the Contractor, in accordance with the terms and conditions of this Contract,
shall develop, maintain, and provide behavioral health services in the county jails for
individuals highlighted in section 1.2. The Contractor, in providing required services
hereunder, shall utilize and maintain a partnership with community provider(s)/individuals
that are licensed (LAC, LPC, LCSW or LMFT), who are in good standing with the
Department of Regulatory Agencies (DORA), have the ability to provide services within the
jail or through televideo options, and have the capacity to provide free or low cost services
in the community to inmates upon release.
Article 2
Activities & Services
2.1 Services. It is best practice that all jails should be utilizing evidence-based screening
Exhibit A-1
Page 10 of 23
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tool(s) and practices to screen for any potential mental health and/or substance use disorders
and withdrawal, as well as suicide risk.
The Contractor shall:
a. Provide adequate staff to complete behavioral health screenings, prescribe psychiatric
medications as necessary; and provide mental health counseling, substance use disorder
treatment and transitional care coordination.
b. Upon identification of an individual who may be a candidate for JBBS services, a referral by
jail staff should be made to a JBBS clinician within 48 hours, or, when the individual is medically
cleared to be screened, via the appropriate channels (e.g. inmate kite, email).
c. Assess all individuals booked into the jail facility for psychiatric medication needs by
requesting and reviewing medical and prescription history.
d. Have access to psychiatric medications, as defined by the medication formulary established
pursuant to section 27-70-103 or by their contracted medical provider.
e. Coordinate services with local community behavioral health providers prior to the release of
an inmate to ensure continuity of care following his or her release from the jail.
f. Complete the GAIN 3.2 assessment with an individual enrolled in the JBBS program within 14
calendar days of program enrollment. The Contractor shall monitor and make reasonable efforts
to ensure that all participants complete a GAIN assessment a minimum of every three months
thereafter, to track progress. Other site-specific tools may also be utilized in addition to the
GAIN.
2.2 Training and Meetings. The Contractor shall provide training to improve correctional staff
responses to people with mental illness. The Contractor shall determine the amount of
training necessary to ensure, at a minimum, a group of trained staff is able to cover all time
shifts. The training should provide sufficient opportunities for hands-on experiential learning,
such as role play and group problem solving exercises. Cross-training opportunities shall be
provided to behavioral health personnel and other stakeholders to help improve cross-system
understanding. BHA is able to provide assistance with training the Medical Team staff regarding
the MAT services and resources across the state.
a. Program Orientation: The Contractor shall attend a mandatory orientation session with the
BHA Program Manager and Fiscal Staff, to be organized by BHA as soon as is practicable
execution of the contract.
b. Program Meetings and Required Training: Program meetings and other required training will
be scheduled throughout the term of the JBBS Program contract. This includes the JBBS
Learning Community, JBBS Round Table, and the JBBS Quarterly Workgroup.
2.3 Evidence-Based Practices. The Contractor shall use evidence-based and promising
practices within the screening and service delivery structure to support effective outcomes.
The use of a risk/need/responsivity (RNR) model is encouraged to assess various factors
such as substance use disorders, mental illness, cognitive or physical impairments, financial
issues, family dynamics, housing instability, developmental disabilities, low literacy levels, and
lack of reliable transportation, all of which may need to be addressed to support success.
2.4 Individualized Service Provision. The Contractor shall link individuals referred to the
program to community based behavioral health supports and services, as appropriate
based on the specific needs of the individual to ensure wraparound services are in place to
reduce the risk of the individual returning into the justice system.
Exhibit A-1
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Article 3
Standards and Requirements
3.1 Mental Health Treatment Provider. The subcontracted mental health treatment
provider(s)/individual(s) must be licensed and in good standing with the Department of
Regulatory Agencies (DORA). The subcontracted mental health treatment provider(s) must
adhere to all rules and regulations set forth by their license and are prohibited from practicing
outside their scope of training.
Article 4
Deliverables
4.1 For Deliverables under this section, please see Part 6 - JBBS Program Deliverables
PART FOUR - PRE-SENTENCE REENTRY COORDINATOR SERVICES
Article 1
Purpose & Target Population
1.1 Purpose. In July 2019, the Behavioral Health Administration (BHA) was granted funds
by the Correctional Treatment Fund Board for Pre-sentence Reentry Coordinator position(s) in
select jails. This program shall provide services to individuals at county jails who are in need of
behavioral health treatment and are on pre-sentence status.
The intention of this position is to work to enhance and improve care coordination for individuals
in county jails with shorter incarcerations (actual length to be determined by individual jails),
which may prevent them from receiving more meaningful, long term interventions by behavioral
health treatment staff. This position is responsible for facilitating communication and
collaboration between judicial and behavioral health systems.
1.2 Target Population. Adults 18 years of age and older, that are residing in the jail awaiting
sentencing. Priority should be given to those identified to be a high jail utilizer (three or more
arrests in a year).
Article 2
Activities & Services
2.1 JBBS Pre-Sentence Reentry Coordinator Services. The Contractor shall refer
individuals to behavioral health services, after the booking process is complete and specific
needs of the individual are identified, to ensure wraparound services are in place to reduce
Exhibit A-1
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the risk of the individual returning into the justice system. Below is a list of services Contractor
shall provide:
a. Behavioral Health Screening: The Contractor shall coordinate with the existing jail processes
to identify the population that will have a shorter length of stay within the jail and who screen
positive for a substance use disorders, co-occurring mental health and substance use disorders,
and/or are identified to be a suicide risk.
b. High Jail Utilizers: The Contractor shall identify individuals that have three or more arrests in
the past year, and shall be a priority population to receive services to target the needs.
c. Brief Intake Assessment. The Contractor shall provide a brief intake to assess immediate
behavioral health needs within 48 hours. BHA recommends using the Risk Need Responsivity
Model https://tools.gmuace.org/files/RNR_Practitioner_Pub_FINAL_2.12.13.pdf
d. Open Referral Process. The Contractor shall facilitate an open referral process with inmates
where transitional resource packets are shared, reviewed and completed. The JBBS Pre-
sentence Reentry Coordinator shall make referrals and coordinate services with licensed or
certified behavioral health professionals, prior to the release of an inmate, to ensure continuity
of care. The JBBS Pre-Sentence Reentry Coordinator shall make referral appointments based
upon need and provide the appointment date to the individual before release.
e. Intervention/Therapy. The Contractor shall offer brief intervention and/or therapy to inmates
as necessary.
f. Coordinate Referral Information. The Contractor shall coordinate with community entities as
applicable (i.e., pre-trial, probation, community corrections, therapeutic communities) to ensure
the supervision entities are made aware of the individual’s assessed needs and scheduled
appointments.
2.2 Service Provision.
a. A report of high jail utilizers should be run every five to seven days. Based on this list, JBBS
staff should review those who would not qualify for pre-sentence reentry coordination services.
This could include, but is not limited to, Department of Corrections holds, out of county warrants,
serious violent crimes.
b. Once that list is reviewed, the PSC should meet with those individuals to identify their needs.
The BHA recommends using the Risk-Need Responsivity Simulation Tool.
https://tools.gmuace.org/files/RNR_Practitioner_Pub_FINAL_2.12.13.pdf
c. Based on the information gathered through this tool (and other information where
applicable), the presentence coordinator should be creating a discharge packet that should be
given to the individual upon their release.
d. A discharge plan should include (but is not limited to) referral/resource information for the
following categories: mental health services, medication, substance abuse services, medication
assisted treatment, health care/medical services, benefits, food, clothing, transportation,
housing, identification needs, employment, and disability income resources.
e. If the individual wants their discharge plan shared with any of the referral community
agencies, they will need to sign a release of information.
f. If an individual is sentenced, it is expected that the presentence coordinator helps them with
appointments in the community prior to their release. This can also include working with
attorneys, probation officers, or parole officers to gain acceptance to sober living or treatment
Exhibit A-1
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programs. If a client reports opiate use, they should be referred to medical for the appropriate
MAT services.
g. Seek partnerships with the Regional Accountable Entity (RAE) to ensure referrals
are made in a timely manner with community treatment providers.
2.3 Data Accessibility. The Pre-Sentence Reentry Coordinator position shall be given
access to, receive training on, and be able to utilize the data in the Jail Management
System (JMS) in order to target the high jail utilizers.
2.4 Data Entry. All discharge plans/notes are entered under the services tab as
“Community Resources and Access”. Any additional follow up should be entered under the
services tab utilizing the drop down option that most closely represents what services are being
provided.
Article 3
Deliverables
3.1 For Deliverables under this section, please see Part 6 - JBBS Program Deliverables
PART FIVE - MEDICATION ASSISTED TREATMENT
Article 1
Purpose & Target Population
1.1 Purpose. Treatment of individuals with substance use disorders who come into contact
with the criminal justice system. Jails that receive funding through the jail-based behavioral
health services program are to allow medication-assisted treatment to be provided to
individuals in the jail. Jails must have services involving consideration for Fentanyl/Carfentanil
related substances, and provide 8 mg of Naloxone at release (this can be two 4mg Narcan or
one 8mg Kloxxado). The jail may enter into agreements with community agencies and
organizations to assist in the development and administration of medication-assisted treatment.
"Medication-Assisted Treatment" or "MAT'' means a combination of behavioral therapy and
medications approved by the Federal Food and Drug Administration to treat SUD disorders.
1.2 Target Population. Adults 18 years of age and older, residing in county jail(s).
Article 2
Activities & Services
2.1 Provision of Medication-Assisted Treatment. Contractor shall hire technical
assistance (“TA”) providers to support MAT programs in their facility. Technical assistance
includes development and implementation of medication-assisted treatment, approval of
prescribers by the United States Drug Enforcement Agency, other appropriate withdrawal
management care, and assistance with identifying bulk purchasing opportunities for
necessary services. The facility shall offer medication approved by the federal Food and Drug
Administration that are approved to treat opiate use disorder, which must include agonists,
Exhibit A-1
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partial agonists, and antagonists, to a person in custody with an opiate use disorder. The
person, in collaboration with the treating provider, must be given a choice concerning what
medication is prescribed, based on the facility’s medication formulary. The Contractor or
designee, shall be responsible for documenting individual-level MAT services provided,
including date of service, type of service, duration of service, specific MAT medication provided,
frequency of dosage, and any additional applicable information. Contractors engaging in MAT
treatment shall expand access to care for persons who are incarcerated with substance use
disorder (SUD) through the following activities:
a. Have a policy in place for the provision of Medication-Assisted Treatment (MAT)
and how it will be implemented. A copy of this policy will be provided to the assigned JBBS
Program Manage prior to MAT services being provided.
b. Identify program appropriate individuals via evidence based screening.
c. Link persons with a community based clinical care provider.
d. Initiate MAT for SUD and retain in MAT/optimize retention to MAT while in jail.
e. Provide patient education surrounding SUD and the types of treatment available
in their community.
f. Develop and routinely review individualized treatment plans.
g. Have fentanyl related considerations for withdrawal management.
h. Provide overdose reversal medication at release (this can be two 4mg Narcan or
one 8mg Kloxxado).
2.2 Allowable Expenses. The following are allowable expenses in the provision of MAT
services, reimbursable in accordance with the BHA-approved rate schedule or prior
authorization from JBBS Program Manager. For a full list of allowable medications, please
see the “medications” section in Exhibit B.\
a. Fee for service agreements with Contractors for treatment, medical staff, and medications.
b. Required medications, handled subject to Controlled Substance / Medication Assisted
Treatment licensing requirements, including medications for overdose reversal such as
Naloxone or Kloxxado.
c. DEA licensing services.
d. Temporary or Permanent staffing services for positions related to the implementation of MAT
services. These could be both sworn and civilian positions.
e. Facility and equipment upgrades related to MAT, per JBBS program manager approval.
f. Training and staff development for MAT. Invoice requests are due to BHA as expenses are
incurred. Only one month’s expenses are allowed per invoice.
g. Technical assistance.
h. Training services for jail staff as it relates to MAT.
i. Consultation services for jail staff and community providers as it relates to MAT.
j. Advertising, marketing or public relation services regarding MAT services.
k. Human Services collaboration as it pertains to Medicaid enrollment prior to release from jail.
l. Translation services for those receiving MAT services when needed.
m. Delivery of MAT medications.
n. Community re-entry services as related to MAT services.
Exhibit A-1
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Article 3
Standards and Requirements
3.1 Program Policies and Plans.
a. Contractor shall adhere to the policy or plan for its jail submitted to satisfy the deliverable
described in Part Six, Article 1.5.
b. A Sheriff who is the custodian of a county jail or city and county jail may enter into
agreements with community agencies, behavioral health organizations, and substance use
disorder treatment organizations to assist in the development and administration of medication-
assisted treatment in the jail.
C. Jails are expected to provide a plan to the BHA by December 31, 2024 detailing the
sustainability of their respective MAT programs beyond the fiscal year or when funds are fully
expended. This plan should include how they will continue to provide MAT services and funding
source. Counties are encouraged to use county funding available from a settlement or damage
award from opiate-related litigation to support jails in complying with the requirements of this
section.
3.2 License Requirements.
a. Providers licensed as an Opioid Treatment Program (OTP) shall adhere to various elements
and sections of 2 CCR 502-1 Behavioral Health Rules including but not limited to 21.320 Opioid
Treatment Programs (OTP) and 21.300 Licensing of Substance Use Disorder Programs Using
Controlled Substances.
b. All BHA-licensed agencies (including OTPs) storing and dispensing from stock controlled
substances for the purpose of treating a substance use disorder or withdrawal from a
substances use disorder shall adhere to 2 CCR 502-1 Behavioral Health Rules regarding
21.300: Controlled Substance License Requirements, which includes direction on the safe
storage and handling of controlled substances.
3.3 Level of Program/Care. OTPs seeking a Controlled Substance License must also apply for
approval to operate as a Behavioral Health Entity (BHE), identifying which ASAM level of care
they will choose to operate at and follow BHA regulatory guidelines that define that level of care
within 2 CCR 502-1.
Article 4
Deliverables
4.1 For Deliverables under this section, please see Part 6 - JBBS Program Deliverables
PART SIX - JBBS PROGRAM DELIVERABLES
Article 1
1.1 Deliverables for All JBBS Programs
Exhibit A-1
Page 16 of 23
DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
a. JBBS Work Plan. Using the JBBS Statement of Work, the Contractor is required to design a
work plan based on the five criteria listed below. The Annual Work Plan should specify the
following information for each service in which the Contractor will participate in. See JBBS Work
Plan Template at the end of this document.
b. Annual Report. The Contractor shall submit to the State the previous year’s Annual Report by
EOB August 1, utilizing the JBBS Reporting Template provided by BHA. The Contractor shall
submit this report via email to cdhs_jbbs@state.co.us
c. JBBS Database Reporting.
i. The Contractor or designated subcontractor shall complete all applicable data fields in
the JBBS (Civicore) Database using the following URL:
https://fw.civicore.com/jbbhs or another data system as prescribed by BHA.
All data entry shall be updated on an ongoing basis, and must reflect current
individual enrollment and services provided by the 15th of each month following
the month when the service was provided.
d. Data Entry shall include:
i. Basic individual demographic and working diagnosis information.
ii. Booking date (date that the individual was booked into jail).
iii. Screening date and results
iv. Admission date (date that individual began receiving JBBS services).
v. Individual-level services provided (date of service, type of service, duration of service,
and any additional information), including any Medication Assisted Treatment services
provided (date of service, duration of service, type of MAT service, specific MAT
medication, and any other applicable information, including frequency of dosage).
vi. Date, duration, and participants who attended for treatment or case management
group sessions.
vii. Discharge date and type (unsuccessful discharge or successful discharge,
depending on whether the individual is actively participating in the JBBS program at the
time of discharge). BHA utilizes discharge and admission dates to approximate sentence
length and measure progress toward shortening sentence lengths.
viii. Date tracked and treatment status in the community, tracked at month 1, month 2,
month 6, and month 12 after discharge.
ix: The contractor shall utilize the Health Information Exchange platform (if available in
the jail) that serves to provide an additional relevant source of longitudinal health data
that can inform & support better treatment options, coordination of care and a better
understanding of the whole health of each individual so they can provide the safest and
most effective treatment recommendations.
e. The Contractor or Contractor’s designated subcontractor shall complete Drug Alcohol
Coordinated Data System (DACODS), Colorado Client Assessment Records (CCAR), and
Encounters - or other BHA prescribed data system records, according to the following schedule:
i. Encounters are due by the last business day of each month for all services provided
during the previous month.
ii. CCARs are due by the last business day of the month following the admission, annual
update, or discharge of a client.
Exhibit A-1
Page 17 of 23
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iii. DACODS are due by the 15th of the following month for admissions into, and
discharges from, JBBS services. See the latest version of the Finance & Data Protocol
Protocol #1 Special Studies Codes and Eligibility for more details:
https://www.google.com/url?q=https://bha.colorado.gov/sites/bha/files/documents/FINAL
%2520Protocol%25201%2520Amendment%25208%2520SSCs%2520and%2520Eligibil
ity%2520October%25202022%2520%25281%2529_0.pdf&sa=D&source=docs&ust=17
09671223916104&usg=AOvVaw0TLJg4bpMoZBfrGf6F2lNE
f. Workgroup Attendance. BHA facilitates JBBS Program Meetings every other month. The
Contractor shall ensure that a representative from each jail participates in the meetings. The
representative(s) who attends the meetings shall be responsible for relaying the information
discussed during the meetings to the rest of the Contractor’s program organizational structure.
g. Critical Incidents. The Contractor shall ensure any critical incident involving a JBBS client is
documented and shared with the Behavioral Health Administration via an encrypted email to
cdhs_ci_bha@state.co.us, within 24 hours of the time the incident occurs. It is
recommended that the Contractor include this reporting requirement in all subcontractor
agreements. The documentation should include the following:
i. Date and time of incident.
ii. Location of the incident.
iii. The nature of the incident.
iv. How the incident was resolved.
v. Name[s] of staff present.
vi. Whether the incident resulted in any physical harm to the participant or
any staff.
h. Copy of Proposed Subcontract. The Contractor shall provide to BHA a copy of all
subcontracts between the Contractor and any potential provider of services to fulfill any
requirements of this Contract, to cdhs_jbbs@state.co.us within 30 days of subcontract
execution. The subcontract will be evaluated to ensure it is in compliance with the maximum
rates established in the Annual Budget document provided by BHA.
i. Site Visits. The JBBS Program Manager(s) may conduct site visits for the purpose of providing
technical assistance support and quality assurance monitoring of the program on a periodic/as
needed basis.
j. Monthly Contract Monitoring Tool. The Contractor shall submit a completed contract
monitoring tool to their assigned JBBS program manager no later than the 20th of the month
with the prior months information. JBBS program managers will update this internally.
k. Plan of Action. Contractors who do not meet the deliverables above, or any additional
deliverables listed below, for which they have been provided funding, may be asked to submit a
plan of action to improve program performance for the current or following fiscal year.
l. Monthly BHA Invoice. Invoices will be submitted to cdhs_bhapayment@state.co.us by the
20th of the following month. Only one month’s expenses are allowed per invoice. Supporting
financial documentation is also required to be submitted along with the invoice.
m. Spending Projection Plan. If a contractor is underspent by greater than 40% of their budget
by mid fiscal year (Nov 30), Contractor shall submit a spending projection plan. Failure to submit
the spending plan and failure to effectively utilize funding could result in reduction in the current
year budget.
Exhibit A-1
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n. Behavioral Health Screenings:
i. Individuals involved in the JBBS program are required to complete the GAIN 3.2
assessment with an individual enrolled in the JBBS program within 14 calendar days of
program enrollment.
1.2 Additional Deliverables Related to Jail Medication-Assisted Treatment
a. Organizational Structure. All Contractors participating in JBBS shall determine and provide an
organizational structure designed to facilitate and promote effective MAT program
administration. Describe the use of evidence based best practices for coordination of care for
identified inmates. This report is due via email to cdhs_jbbs@state.co.us by August 1 annually.
b. Policies. Prior to MAT services being delivered, the Contractor shall provide BHA a written
policy for their intended Jail MAT service delivery method, via email to cdhs_jbbs@state.co.us.
Contact JBBS Program Manager for additional information on creating MAT policies.
c. Barrier Reports. If Contractor does not deliver any part of these deliverables, Contractor shall
submit a report detailing the barrier(s) Contractor is experiencing that have prevented the
service delivery. Describe the capacity or efforts needed to get the jail into compliance, including
but not limited to withdrawal management, screening, and coordination of care for inmates
identified for MAT. The report is due via email to cdhs_jbbs@state.co.us by August 1 annually.
d. Work Plan and Budget Submission/Approval. In order to access MAT funds, Contractor must
submit a MAT work plan describing how the funds will be used.
e. Contractor shall provide an initial budget to the BHA JBBS Program Manager with Contractor
submission of the work plan. BHA JBBS Program Manager will respond with an approval, a
request for more information, or a rejection with cause. Budgets in excess of the proposed soft
cap must be approved in advance in writing by the BHA JBBS Program Manager.
f. Contractors with ongoing MAT programs must submit the workplan and budget by June 1
annually for the upcoming state fiscal year (beginning July 1). Contractors beginning new MAT
programs must submit the workplan and budget prior to commencing services billed to this fund.
Contractor work may not commence until the work plan and budget are approved by the BHA
JBBS Program Manager.
g. Data Entry. The Contractor or designated subcontractor shall complete all applicable data
fields as outlined in Part Six, Table 1, page 19. Data shall be entered in the JBBS (Civicore)
database, or another data system as prescribed by BHA. All data entry shall be updated on an
ongoing basis, and must reflect current individual enrollment and services provided by the 15th
of each month following the month when the service was provided.
h. Medication Compliance - Number of individuals who have engaged in MAT services under
the JBBS umbrella, who have successfully transitioned to a provider for further treatment or
ongoing evaluation for MAT services, including community-based or Department of Corrections
settings.
Exhibit A-1
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Table 1
Below is the deliverables table required by BHA for each JBBS related service.
Program Deliverable Due Date Responsible
Party
Deliver to
All Send BHA
copies of all
proposed
subcontracts
Within 30
days of
contract
being signed
Contractor cdhs_jbbs@state.co.us
All Provide work
plan
With budget
submission
Contractor cdhs_jbbs@state.co.us
All Submit BHA
invoice &
supporting
financial
documents
By the 20th
of the
following
month
Contractor
cdhs_obhpayment@state.co.us
All Report critical
incidents
Within 24
hours of
incident
Contractor cdhs_ci_obh@state.co.us
All Provide
JBBS annual
report
8/1/25 Contractor cdhs_jbbs@state.co.us
All Site Visits Ongoing / As
Needed
BHA Locations TBD
Exhibit A-1
Page 20 of 23
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All Contract
Monitoring
Tool
Ongoing, by
the 20th of
each month
for all
services
provided
during the
previous
month
Contractor
JBBS Program Manager
All Program
specific data
Ongoing Contractor or
designated
subcontractor
Civicore database
All Workgroup
attendance
Ongoing Contractor,
subcontractors,
clinicians
Virtual formats - invites will be
provided by JBBS program
managers
MAT Provide jail
MAT program
policies and
procedures
Prior to MAT
services
being
provided
Contractor cdhs_jbbs@state.co.us
Exhibit A-1
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DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
JBBS Work Plan
1. Identify the Project Name, Purpose and Timeline
i. The Project Name will be either JBBS/Substance Use Disorder Treatment,
JBBS/Mental Health Treatment, JBBS/Pre-Sentence Coordinator, or JBBS/Medication
Assisted Treatment (MAT).
ii. The Purpose will include what you hope to accomplish by providing JBBS services in
your facilities.
iii. The Timeline will be July 1, 2024 - June 30, 2025
2. Put Your Work Plan Into Context
i. This should include an introduction and background of the facility’s JBBS program.
ii. Write an introduction and background to better outline why you need this project to
happen - Creating context and establishing the problem, helps explain why you need the
solution. Examples could include an increase in substance abuse usage, increase in
mental health disorders, increased jail population, high recidivism rates, Colorado state
statute requirements, etc…
iii. Describe the overall goal of the JBBS program. Examples can include who is eligible
for services, how will referrals to the program be made, what are the admission criteria,
how services will be provided, etc…
iv. If the facility is a new JBBS program, please include a brief summary of how and why
JBBS services will be implemented into your facility, and what you hope to gain from this
program.
3. Establish Your Goals and Objectives. Goals and objectives should be developed in an
integrated, multi-disciplinary fashion, which includes the active and ongoing participation of the
offender, jail staff and community providers. Examples could include:
i. What are / will be, the assessments and screenings between subcontracted treatment
provider agencies?
ii. How will you interface with other agencies serving persons with substance use
disorders or co-occurring mental illnesses, (i.e., community mental health centers,
substance use disorder treatment programs, service programs for Veterans, community
service agencies, and other licensed clinicians in private practice), to meet individuals’
treatment needs?
iii. What is the service array available within the community to program participants upon
their release from jail, OR, if there are limited services available in your area, highlight
this as a potential barrier.
iv. Which recovery support services (RSS) are most needed in your community and/or
catchment area and how will the provider or Sheriff’s Department use a portion of their
budget to meet these needs?
v. What security protocol and reporting requirements are expected from the treatment
provider?
Exhibit A-1
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vi. What is the current capacity or efforts to screen all individuals booked into the jail
facility for mental health, suicidality and substance use histories and needs?
vii. What are/will be, the continuum of services being offered, pursuant to this Contract
based on evidence based curricula?
vii. What will the frequency and duration of services offered look like? Discuss the
availability of services during the week and hours of operation, as well as include a
breakdown of staff time (FTE) allocated to the program, credentials and general duties of
each position.
4. Define and Coordinate Your Resources:
i. Determine and provide an organizational structure designed to facilitate and promote
effective administration of the JBBS program (should include jail staff as well as any
subcontracted staff).
ii. Describe how you plan to link offenders with community services
upon their release from custody.
5. Understand Your Constraints: Are there any obstacles that are going to get in the
way of providing these services?
i. Examine if there are any barriers to treatment within the jail? Within the community?
ii. If so, it is possible to address these and, if so, how do you plan to do that?
6. Discuss Risks and Accountability: Here you will highlight any foreseeable risks to the
program, as well as who will be accountable for each aspect of the program.
i. Activities, services, budgets, plans, timelines, goals, and outcome measures included
in the Work Plan shall be interpreted as being material contractual performance
requirements, outcomes, measures, and contract deliverables of the Contractor.
ii.The work plan, once approved by BHA, shall be incorporated into this Contract by
reference as work requirements of the Contractor supplemental to Contractor work
requirements under the current Contract Exhibit A, Statement of Work, as amended.
Exhibit A-1
Page 23 of 23
DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
BHA Program JBBS
Project Name JBBS
MD/DO *
Pharmascist (Pharm-D)
Registered Nurse *
Data Entry Clerk
Peer Support Specialist
Qualified Medication Administration Person (QMAP)
Total Contract $84,000.00
JBBS RATE SCHEDULE
Mental Health Treatment State General Fund $36,120.00
Statewide Maximum Salaries
Positions should be hired at salary levels indicative of qualifications, experience, and organization pay schedules. This table indicates a maximum salary
only. It is understood that many positions will be hired at lower salary levels than the state maximum.
Licensed Therapist (LPC/LCSW/LAC/LMFT)*$84,872/year
Unlicensed Master's Level Therapist or Substance Abuse Counselor (example CAS)*$68,959/year
Unlicensed Bachelor's Level Therapist or Substance Abuse Counselor (example CAS)*$63,654/year
$58,349/year
JBBS Program Administrator (Primary responsibility of managing the jail's JBBS
program.) *
Pre-sentence Coordinator *
Case Manager (CM) *
Certified Addiction Technician (CAT)$44,558/year
Physician Assistance (PA) *$127,308/year
$266,569/year
$103,538/year
$72,100/year
EXHIBIT B-1, FY25 ANNUAL BUDGET
Agency Name Eagle County
Program Contact, Title Sarah Kenndy,Program Coordinator
Phone 970-328-8541
Email sarah.kennedy@.ueaglecountys
March 25, 2024
State General Fund $47,880.00
Email
Date Completed
SERVICE CATEGORIES
Services (Fixed Price per rate Schedule)Funding Source Total
Substance Use Disorder Treatment
Budget Period July 1, 2024 - June 30, 2025
Fiscal Contract, Title Sarah Kenndy,Program Coordinator
Phone 970-328-8541
sarah.kennedy@.ueaglecountys
$135,891/year
$76,385/year
$42,436/year
$36,050/year
$15.97/hour
*BHA will reimburse salaries up to the state maximum
*BHA may consider rates 10% above statewide maximum salaries pending justification from jails and written pre-approval by BHA
Travel
Mileage (IRS rate)$0.67/mile
Operating Expenses
Maximum total percentage of contract budget 10%
Training and continuing education for jail employees/clinicians (including but not limited to QMAP, CIT, Motivational Interviewing, Mental Health First Aid, Trauma
Informed Care, (Certified Addiction Specialist -Classes only) may be included in the operating expenses
BHA may pay for one licensing test per clinician (NCE, MAC, NCAC). Up to $200 per clinician, per test.
BHA may consider operating expenses above 10% of total contract budget pending justification from jails and written pre-approval by BHA
Indirect Expenses
10%
BHA may consider operating expenses above 10% of total contract budget pending justification from jails and written pre-approval by BHA
RECOVERY SUPPORT SERVICES
Maximum total percentage of contract budget
Allowed Services *
Application Fees ID / Birth Certificates
Indigent Backpacks
Basic Hygiene Items
Bicycles
Bus Pass – Daily, Monthly
Additional Notes
May be provided if client is engaged in treatment services for 2 + months post
release. 1 bike per person.
1 month limit per client, per childChild Care
FY24 JBBS Budget
Exhibit B-1
Page 1 of 2
DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
Food Assistance
Revised 03_04_2024
Transportation Assistance
Transportation to Residential Treatment
UA / BAs
Utilities
Life Skills Training
Medical Assistance – copays / infectious disease testing
Medications
Personal Care (eg. haircuts)
Phone Cards
Pre-paid Cell Phones
Printed Resources
Out of state travel to treatment will need prior approval by BHA
Limit of $100.00 per person
1 month limit per client
Limit of $250.00 per person
30 day limit per person
Limit of $15.00 per person
To be paid for upon release and after client attends 2 appointments in the
community.
Cost of the phone and up to 2 months of bills.
* BHA may consider other expenses pending justification from jails and written pre-approval by BHA
MEDICATIONS
Medication reimbursement will be based on a) providers established rate or b) jail purchase agreement rate or c) in the absence of an established rate or jail
purchase agreement rate the following BHA rate schedule.
Psychotropic Medication will be reimbursed at rate established on Preferred Drug List (PDL) which can be found at
https://www.colorado.gov/hcpf/pharmacy resources
Medication Rate
Methadone $18/day. Methodone treatment, including medication and integrated psychosocial and
Naltrexone (oral)Monthly Medication Rate: $85. Monthly Prescriber Rate: $150
$140/month
$140/month
$80/month
Unit Cost: $75. Prescriber Rate: $35
$5.55 / unit @30 days = $166.50 for a 2mg-0.5mg dose; range can increase from 4mg-
$41/month
$31/month
$1,376/unit; 380mg injection (extended release) per month
Depot-naltrexone (injectable) (Vivitrol)$1,376/unit; 380mg injection (extended release) per month
Buprenorphine (pregnancy) - 8mg $41/month
Buprenorphine (pregnancy) - 2mg $31/month
$275/month
Buprenorphine - 2mg
Sublocade (injectable)
Buprenorphine/naloxone sublingual film (suboxone) - 12mg/3mg
Buprenorphine/naloxone sublingual film (suboxone) - 8mg/2mg
Buprenorphine/naloxone sublingual film (suboxone) - 4mg/1mg
Buprenorphine/naloxone sublingual film (suboxone) - 2mg/0.5mg
Naloxone (Narcan)
Suboxone and generics
Buprenorphine - 8mg
Clothing
Educational Costs ( books, supplies, and fees)
Emergency Housing/Rental Assistance
Gas Vouchers
GED Program / Testing
Job Placement Training
90 day limit per person
FY24 JBBS Budget
Exhibit B-1
Page 2 of 2
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Exhibit C-1
Page 1 of 5
Exhibit C-1
Miscellaneous Provisions
I. General Provisions and Requirements
A. Finance and Data Protocols
The Contractor shall comply with the Behavioral Health Administration’s (BHA) most current
Finance and Data Protocols and the Behavioral Health Accounting and Auditing Guidelines,
made a part of this Contract by reference.
B. Marketing and Communications
The Contractor shall comply with the following marketing and communications requirements:
1. Reports or Evaluations. All reports or evaluations funded by BHA must be reviewed
by BHA staff, including program, data, and communications, over a period of no
fewer than 15 business days. The Contractor may be asked to place a report or
evaluation on an BHA template and the report or evaluation is required to display
the BHA logo. The Contractor shall submit the finished document to BHA in its
final format and as an editable Word or Google document.
2. Press Releases. All press releases about work funded by BHA must note that the
work is funded by the Colorado Department of Human Services, Behavioral Health
Administration. Press releases about work funded by BHA must be reviewed by
BHA program and communications staff over a period of no fewer than five
business days.
3. Marketing Materials. Contractor shall include the current Colorado Department of
Human Services, Behavioral Health Administration logo on any marketing
materials, such as brochures or fact sheets, that advertise programs funded by this
Contract. Marketing materials must be approved by the Contract’s assigned BHA
program contract over a period of no fewer than 5 business days.
4. All Other Documents. All other documents published by the Contractor about its
BHA-funded work, including presentations or website content, should mention the
Colorado Department of Human Services, Behavioral Health Administration as a
funder.
5. Opinion of BHA. BHA may require the Contractor to add language to documents
that mention BHA reading: “The views, opinions and content expressed do not
necessarily reflect the views, opinions or policies of the Colorado Department of
Human Services, Behavioral Health Administration.”
C. Start-up Costs
If the State reimburses the Contractor for any start-up costs and the Contractor closes the
program or facility within three years of receipt of the start-up costs, the Contractor shall
reimburse the State for said start-up costs within sixty (60) days of the closure. The Contractor
is not required to reimburse the State for start-up costs if the facility or program closure is due
to BHA eliminating funding to that specific program and/or budget line item.
DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
Exhibit C-1
Page 2 of 5
D. Immediate Notification of Closures / Reductions in Force
If the Contractor intends to close a facility or program, it shall notify the BHA Contracts Unit
at least five business days prior to the closure. Similarly, if the Contractor, or any sub-
contractor provider, intends to conduct a reduction in force which affects a program funded
through this contract, the Contractor shall notify the BHA Contracts Unit at least five business
days prior to the layoffs.
E. Contract Contact Procedure
The Contractor shall submit all requests for BHA interpretation of this Contract or for
amendments to this Contract to the BHA Contract Manager.
F. Continuity of Operations Plan
1. In the event of an emergency resulting in a disruption of normal activities,
BHA may request that Contractor provide a plan describing how Contractor
will ensure the execution of essential functions of the Contract, to the extent
possible under the circumstances of the inciting emergency (“Continuity of
Operations Plan” or “Plan”).
2. The Continuity of Operations Plan must be specific and responsive to the
circumstances of the identified emergency.
3. BHA will provide formal notification of receipt of the Continuity of
Operations Plan to the Contractor.
4. The Continuity of Operations Plan will not impact or change the budget or
any other provisions of the contract, and Contractor's performance will be
held to the same standards and requirements as the original Contract terms,
unless otherwise specified in the Continuity of Operations Plan.
5. Any submitted Continuity of Operations Plan will be ratified as an
amendment to the contract as soon as possible.
6. Contractor shall communicate, in a format mutually agreed upon by BHA
and Contractor staff, on a frequency that supports the monitoring of services
under the Continuity of Operations Plan. If adjustments are needed to the
Plan, such adjustments will be made in writing and accompanied by written
notice of receipt from BHA.
a. As part of the BHA/Contractor communication during the emergency,
Contractor and BHA will evaluate whether the emergency has
resolved such that normal operations may be resumed.
b.Contractor and BHA will agree in writing when the emergency
situation is sufficiently resolved and agree to a closeout period that is
four weeks or less.
c. BHA will submit notice accepting the termination of the Continuity
of Operations Plan to the Contractor as the final action for any
qualifying emergency response.
DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
Exhibit C-1
Page 3 of 5
G. Cultural Responsiveness in Service Delivery
1. The Behavioral Health Administration expects funding dollars to support equity in
access, services provided, and behavioral health outcomes among individuals of all
cultures, gender identities, sexual orientations, races, and ethnicities. Accordingly,
Contractors should collect and use data to: (1) identify priority populations vulnerable
to health disparities encompassing the contractor's entire geographic service area
(e.g., racial, ethnic, limited English speaking, indigenous, sexual orientation, gender
identity groups, etc.) and (2) implement strategies to decrease the disparities in access,
service use, and outcomes—both within those subpopulations and in comparison to
the general population.
2. One strategy for addressing health disparities is the use of the recently revised
National Standards for Culturally and Linguistically Appropriate Services in Health
and Health Care (CLAS). The U.S. Department of Health and Human Services (HHS)
Think Cultural Health website (https://thinkculturalhealth.hhs.gov/) also features
information, continuing education opportunities, resources, and more for health and
health care professionals to learn about culturally and linguistically appropriate
services, or CLAS.
3. Contractors providing direct behavioral health prevention, treatment, or recovery
services shall submit one of the following two documents to
CDHS_BHAdeliverables@state.co.us by August 31 annually:
a. If a provider has completed an equity plan that identifies how they will
address health equity, they can submit the plan or;
b.Submit a completed CLAS checklist that follows this HHS format:
https://thinkculturalhealth.hhs.gov/assets/pdfs/AnImplementationChecklistfort
heNationalCLASStandards.pdf
H. Prohibition on Marijuana. Funds may not be used, directly or indirectly, to purchase,
prescribe, or provide marijuana or treatment using marijuana. Treatment in this context
includes the treatment of opioid use disorder. Funds also cannot be provided to any individual
who or organization that provides or permits marijuana use for the purposes of treating
substance use or mental disorders. This prohibition does not apply to those providing such
treatment in the context of clinical research permitted by the DEA and under an FDA-
approved investigational new drug application where the article being evaluated is marijuana
or a constituent thereof that is otherwise a banned controlled substance under federal law.
II. Use of Subcontracts.
A. Services described in this Contract may be performed by Contractor or by a subcontractor,
except where this Contract states explicitly that a service must not be subcontracted.
1. To the extent a subcontractor is used, the Contractor shall provide a copy of the subcontract
to BHA at CDHS_BHAdeliverables@state.co.us.
2. Contractor shall ensure that its subcontractors perform to the terms of this Contract as set
forth in the Contract provisions.
DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
Exhibit C-1
Page 4 of 5
B. Any subcontract for services must include, at a minimum, the following:
1. A description of each partner’s participation
2. Responsibilities to the program (policy and/or operational)
3. Resources the subcontractor will contribute, reimbursement rates, services to be included
and processes in collecting and sharing data and the most recent CDHS version of the
HIPAA Business Associates Addendum, if this Contract contains the HIPAA Business
Associates Addendum/Qualified Service Organization Addendum as an exhibit.
4. A copy of this Contract and all its terms and conditions.
C. The Contractor shall provide to BHA a copy of any proposed subcontract between the
Contractor and any potential provider of services to fulfill any requirements of this Contract, to
CDHS_BHAdeliverables@state.co.us within 30 days of subcontract execution.
D. BHA reserves the right to require Contractor to renegotiate subcontracts where necessary to
adhere to the terms of this Contract.
E. Subcontractor/Partnership Termination. In the event where partnerships with a subcontractor
such as a treatment provider is terminated, the Contractor shall transition to a new partnership
no later than 30 days from termination to ensure continuity of care for all participants of the
program.
III. Financial Requirements
A. Funding Sources
1. The Contractor shall identify all funds delivered to subcontractors as state general fund,
state cash funds, or federal grant dollars in Exhibit B, “Budget.” The Contractor shall
communicate the CFDA number to all sub-contractors in their sub-contracts.
B. Budget Reallocations
1. The Contractor may reallocate funds between the budget categories of this contract, up to
10% of the total contract amount, upon written approval by BHA, without a contract
amendment. Any allowable reallocation is still subject to the limitations of the
Not to Exceed and the Maximum Amount Available per Fiscal Year.
C. Payment Terms
1. The Contractor shall invoice monthly for services, no later than the 20th of the month
following when services are provided.
2. The Contractor shall utilize the invoice template(s) provided by BHA. Contractor shall
comply with the invoicing instructions contained within the invoice template, and requests
for supporting documentation.
3. All payment requests shall be submitted electronically to
CDHS_BHApayment@state.co.us
4. Year-end invoice estimates are due by June 15th. Final invoice requests in excess of the
submitted estimates are payable contingent on available funds.
5. Final invoices are due no later than August 30th.
DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
Exhibit C-1
Page 5 of 5
6. Invoices for the prior fiscal year received by August 30th which require revisions must be
final by September 10th or they may not be paid.
7. Any requests for payment received after September 10th for the prior state fiscal year cannot
be processed by BHA.
8. The State will make payment on invoices within forty-five (45) days of receipt of a correct
and complete invoice to CDHS_BHApayment@state.co.us. Consequently, the Contractor
must have adequate solvency to pay its expenses up to forty-five (45) days after invoice
submission to the State.
DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
EXHIBIT D-1
HIPAA BUSINESS ASSOCIATE / 42 PART 2
QUALIFIED SERVICE ORGANIZATION AGREEMENT
This HIPAA Business Associate/42 Part 2 Qualified Service Organization Agreement (“Agreement”) between the
State and Contractor is agreed to in connection with, and as an exhibit to, the Contract. For purposes of this
Agreement, the State is referred to as “Covered Entity” and the Contractor is referred to as “Business Associate”.
Unless the context clearly requires a distinction between the Contract and this Agreement, all references to
“Contract” shall include this Agreement.
1.PURPOSE
Covered Entity wishes to disclose information to Business Associate, which may include Protected Health
Information ("PHI"). The Parties intend to protect the privacy and security of the disclosed PHI in compliance
with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), Pub. L. No. 104-191 (1996) as
amended by the Health Information Technology for Economic and Clinical Health Act (“HITECH Act”) enacted
under the American Recovery and Reinvestment Act of 2009 (“ARRA”) Pub. L. No. 111–5
(2009), implementing regulations promulgated by the U.S. Department of Health and Human Services at 45
C.F.R. Parts 160, 162 and 164 (the “HIPAA Rules”) and other applicable laws, as amended. Prior to the
disclosure of PHI, Covered Entity is required to enter into an agreement with Business Associate containing
specific requirements 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 all other applicable laws and regulations, all as may be amended.
2.DEFINITIONS
The following terms used in this Agreement shall have the same meanings as in the HIPAA Rules: Breach, Data
Aggregation, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary,
Notice of Privacy Practices, Protected Health Information, Required by Law, Secretary, Security Incident,
Subcontractor, Unsecured Protected Health Information, and Use.
The following terms used in this Agreement shall have the meanings set forth below:
a.Business Associate. “Business Associate” shall have the same meaning as the term “business
associate” at 45 C.F.R. 160.103 and, and shall refer to Contractor.
b.Covered Entity. “Covered Entity” shall have the same meaning as the term “covered entity” at 45
C.F.R. 160.103, and shall refer to the State.
c.Information Technology and Information Security. “Information Technology” and “Information
Security” shall have the same meanings as the terms “information technology” and “information
security”, respectively, in §24-37.5-102, C.R.S.
Exhibit D-1
Page 1 of 11 HIPAA BAA/QSOA
Revised August 2018
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Capitalized terms used herein and not otherwise defined herein or in the HIPAA Rules shall have the meanings
ascribed to them in the Contract.
3.OBLIGATIONS AND ACTIVITIES OF BUSINESS ASSOCIATE
a. Permitted Uses and Disclosures.
i.Business Associate shall use and disclose PHI only to accomplish Business Associate’s
obligations under the Contract.
i.To the extent Business Associate carries out one or more of Covered Entity’s obligations
under Subpart E of 45 C.F.R. Part 164, Business Associate shall comply with any and all
requirements of Subpart E that apply to Covered Entity in the performance of such obligation.
ii.Business Associate may disclose PHI to carry out the legal responsibilities of Business
Associate, provided, that the disclosure is Required by Law or Business Associate obtains
reasonable assurances from the person to whom the information is disclosed that:
A.the information will remain confidential and will be used or disclosed only as
Required by Law or for the purpose for which Business Associate originally
disclosed the information to that person, and;
B.the person notifies Business Associate of any Breach involving PHI of which it is
aware.
iii.Business Associate may provide Data Aggregation services relating to the Health Care
Operations of Covered Entity. Business Associate may de-identify any or all PHI created or
received by Business Associate under this Agreement, provided the de-identification
conforms to the requirements of the HIPAA Rules.
d.Minimum Necessary. Business Associate, its Subcontractors and agents, shall access, use, and
disclose only the minimum amount of PHI necessary to accomplish the objectives of the Contract, in
accordance with the Minimum Necessary Requirements of the HIPAA Rules including, but not
limited to, 45 C.F.R. 164.502(b) and 164.514(d).
e. Impermissible Uses and Disclosures.
i.Business Associate shall not disclose the PHI of Covered Entity to another covered entity
without the written authorization of Covered Entity.
ii.Business Associate shall not share, use, disclose or make available any Covered Entity PHI in
any form via any medium with or to any person or entity beyond the boundaries or
jurisdiction of the United States without express written authorization from Covered Entity.
f.Business Associate's Subcontractors.
i.Business Associate shall, in accordance with 45 C.F.R. 164.502(e)(1)(ii) and 164.308(b)(2),
ensure that any Subcontractors who create, receive, maintain, or transmit PHI on behalf of
Business Associate agree in writing to the same restrictions, conditions, and requirements that
apply to Business Associate with respect to safeguarding PHI.
Exhibit D-1
Page 2 of 11 HIPAA BAA/QSOA
Revised August 2018
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ii.Business Associate shall provide to Covered Entity, on Covered Entity’s request, a list of
Subcontractors who have entered into any such agreement with Business Associate.
iii.Business Associate shall provide to Covered Entity, on Covered Entity’s request, copies of
any such agreements Business Associate has entered into with Subcontractors.
g.Access to System. If Business Associate needs access to a Covered Entity Information Technology
system to comply with its obligations under the Contract or this Agreement, Business Associate shall
request, review, and comply with any and all policies applicable to Covered Entity regarding such
system including, but not limited to, any policies promulgated by the Office of Information
Technology and available at https://oit.colorado.gov/standards-policies-guides/technical-standards-
policies.
h.Access to PHI. Business Associate shall, within ten days of receiving a written request from Covered
Entity, make available PHI in a Designated Record Set to Covered Entity as necessary to satisfy
Covered Entity’s obligations under 45 C.F.R. 164.524.
i.Amendment of PHI.
i.Business Associate shall within ten days of receiving a written request from Covered Entity
make any amendment to PHI in a Designated Record Set as directed by or agreed to by
Covered Entity pursuant to 45 C.F.R. 164.526, or take other measures as necessary to satisfy
Covered Entity’s obligations under 45 C.F.R. 164.526.
ii.Business Associate shall promptly forward to Covered Entity any request for amendment of
PHI that Business Associate receives directly from an Individual.
j.Accounting Rights. Business Associate shall, within ten days of receiving a written request from
Covered Entity, maintain and make available to Covered Entity the information necessary for
Covered Entity to satisfy its obligations to provide an accounting of Disclosure under 45 C.F.R.
164.528.
k.Restrictions and Confidential Communications.
i.Business Associate shall restrict the Use or Disclosure of an Individual’s PHI within ten days
of notice from Covered Entity of:
A.a restriction on Use or Disclosure of PHI pursuant to 45 C.F.R. 164.522; or
B.a request for confidential communication of PHI pursuant to 45 C.F.R. 164.522.
ii.Business Associate shall not respond directly to an Individual’s requests to restrict the Use or
Disclosure of PHI or to send all communication of PHI to an alternate address.
iii.Business Associate shall refer such requests to Covered Entity so that Covered Entity can
coordinate and prepare a timely response to the requesting Individual and provide direction to
Business Associate.
l.Governmental Access to Records. Business Associate shall make its facilities, internal practices,
books, records, and other sources of information, including PHI, available to the Secretary for
purposes of determining compliance with the HIPAA Rules in accordance with 45 C.F.R. 160.310.
Exhibit D-1
Page 3 of 11 HIPAA BAA/QSOA
Revised August 2018
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m.Audit, Inspection and Enforcement.
i.Business Associate shall obtain and update at least annually a written assessment performed
by an independent third party reasonably acceptable to Covered Entity, which evaluates the
Information Security of the applications, infrastructure, and processes that interact with the
Covered Entity data Business Associate receives, manipulates, stores and distributes. Upon
request by Covered Entity, Business Associate shall provide to Covered Entity the executive
summary of the assessment.
ii.Business Associate, upon the request of Covered Entity, shall fully cooperate with Covered
Entity’s efforts to audit Business Associate’s compliance with applicable HIPAA Rules. If,
through audit or inspection, Covered Entity determines that Business Associate’s conduct
would result in violation of the HIPAA Rules or is in violation of the Contract or this
Agreement, Business Associate shall promptly remedy any such violation and shall certify
completion of its remedy in writing to Covered Entity.
n. Appropriate Safeguards.
i.Business Associate shall use appropriate safeguards and comply with Subpart C of 45 C.F.R.
Part 164 with respect to electronic PHI to prevent use or disclosure of PHI other than as
provided in this Agreement.
ii.Business Associate shall safeguard the PHI from tampering and unauthorized disclosures.
iii.Business Associate shall maintain the confidentiality of passwords and other data required for
accessing this information.
iv.Business Associate shall extend protection beyond the initial information obtained from
Covered Entity to any databases or collections of PHI containing information derived from
the PHI. The provisions of this section shall be in force unless PHI is de-identified in
conformance to the requirements of the HIPAA Rules.
o. Safeguard During Transmission.
i.Business Associate shall use reasonable and appropriate safeguards including, without
limitation, Information Security measures to ensure that all transmissions of PHI are
authorized and to prevent use or disclosure of PHI other than as provided for by this
Agreement.
ii.Business Associate shall not transmit PHI over the internet or any other insecure or open
communication channel unless the PHI is encrypted or otherwise safeguarded with a FIPS-
compliant encryption algorithm.
p. Reporting of Improper Use or Disclosure and Notification of Breach.
i.Business Associate shall, as soon as reasonably possible, but immediately after discovery of a
Breach, notify Covered Entity of any use or disclosure of PHI not provided for by this
Agreement, including a Breach of Unsecured Protected Health Information as such notice is
Exhibit D-1
Page 4 of 11 HIPAA BAA/QSOA
Revised August 2018
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required by 45 C.F.R. 164.410 or a breach for which notice is required under §24-73-103,
C.R.S.
ii.Such notice shall include the identification of each Individual whose Unsecured Protected
Health Information has been, or is reasonably believed by Business Associate to have been,
accessed, acquired, or disclosed during such Breach.
iii.Business Associate shall, as soon as reasonably possible, but immediately after discovery of
any Security Incident that does not constitute a Breach, notify Covered Entity of such
incident.
iv.Business Associate shall have the burden of demonstrating that all notifications were made as
required, including evidence demonstrating the necessity of any delay.
q. Business Associate’s Insurance and Notification Costs.
i.Business Associate shall bear all costs of a Breach response including, without limitation,
notifications, and shall maintain insurance to cover:
A.loss of PHI data;
B.Breach notification requirements specified in HIPAA Rules and in §24-73-103,
C.R.S.; and
C.claims based upon alleged violations of privacy rights through improper use or
disclosure of PHI.
ii.All such policies shall meet or exceed the minimum insurance requirements of the Contract
or otherwise as may be approved by Covered Entity (e.g., occurrence basis, combined single
dollar limits, annual aggregate dollar limits, additional insured status, and notice of
cancellation).
iii.Business Associate shall provide Covered Entity a point of contact who possesses relevant
Information Security knowledge and is accessible 24 hours per day, 7 days per week to assist
with incident handling.
iv.Business Associate, to the extent practicable, shall mitigate any harmful effect known to
Business Associate of a Use or Disclosure of PHI by Business Associate in violation of this
Agreement.
r.Subcontractors and Breaches.
i.Business Associate shall enter into a written agreement with each of its Subcontractors and
agents, who create, receive, maintain, or transmit PHI on behalf of Business Associate. The
agreements shall require such Subcontractors and agents to report to Business Associate any
use or disclosure of PHI not provided for by this Agreement, including Security Incidents and
Breaches of Unsecured Protected Health Information, on the first day such Subcontractor or
agent knows or should have known of the Breach as required by 45 C.F.R. 164.410.
Exhibit D-1
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ii.Business Associate shall notify Covered Entity of any such report and shall provide copies of
any such agreements to Covered Entity on request.
s.Data Ownership.
i.Business Associate acknowledges that Business Associate has no ownership rights with
respect to the PHI.
ii.Upon request by Covered Entity, Business Associate immediately shall provide Covered
Entity with any keys to decrypt information that the Business Association has encrypted and
maintains in encrypted form, or shall provide such information in unencrypted usable form.
t.Retention of PHI. Except upon termination of this Agreement as provided in Section 5, below,
Business Associate and its Subcontractors or agents shall retain all PHI throughout the term of this
Agreement, and shall continue to maintain the accounting of disclosures required under Section 3.h,
above, for a period of six years.
4.OBLIGATIONS OF COVERED ENTITY
a.Safeguards During Transmission. Covered Entity shall be responsible for using appropriate
safeguards including encryption of PHI, to maintain and ensure the confidentiality, integrity, and
security of PHI transmitted pursuant to this Agreement, in accordance with the standards and
requirements of the HIPAA Rules.
b.Notice of Changes.
i.Covered Entity maintains a copy of its Notice of Privacy Practices on its website. Covered
Entity shall provide Business Associate with any changes in, or revocation of, permission to use
or disclose PHI, to the extent that it may affect Business Associate’s permitted or required uses
or disclosures.
ii.Covered Entity shall notify Business Associate of any restriction on the use or disclosure of
PHI to which Covered Entity has agreed in accordance with 45 C.F.R. 164.522, to the extent
that it may affect Business Associate’s permitted use or disclosure of PHI.
5.TERMINATION
a. Breach.
i.In addition to any Contract provision regarding remedies for breach, Covered Entity shall
have the right, in the event of a breach by Business Associate of any provision of this
Agreement, to terminate immediately the Contract, or this Agreement, or both.
ii.Subject to any directions from Covered Entity, upon termination of the Contract, this
Agreement, or both, Business Associate shall take timely, reasonable, and necessary action to
protect and preserve property in the possession of Business Associate in which Covered
Entity has an interest.
Exhibit D-1
Page 6 of 11 HIPAA BAA/QSOA
Revised August 2018
DocuSign Envelope ID: D6F9FA26-1B2F-4655-A541-2CB8E56D72EE
b.Effect of Termination.
i.Upon termination of this Agreement for any reason, Business Associate, at the option of
Covered Entity, shall return or destroy all PHI that Business Associate, its agents, or its
Subcontractors maintain in any form, and shall not retain any copies of such PHI.
ii.If Covered Entity directs Business Associate to destroy the PHI, Business Associate shall
certify in writing to Covered Entity that such PHI has been destroyed.
iii.If Business Associate believes that returning or destroying the PHI is not feasible, Business
Associate shall promptly provide Covered Entity with notice of the conditions making return
or destruction infeasible. Business Associate shall continue to extend the protections of
Section 3 of this Agreement to such PHI, and shall limit further use of such PHI to those
purposes that make the return or destruction of such PHI infeasible.
6.INJUNCTIVE RELIEF
Covered Entity and Business Associate agree that irreparable damage would occur in the event Business
Associate or any of its Subcontractors or agents use or disclosure of PHI in violation of this Agreement, the
HIPAA Rules or any applicable law. Covered Entity and Business Associate further agree that money damages
would not provide an adequate remedy for such Breach. Accordingly, Covered Entity and Business Associate
agree that Covered Entity shall be entitled to injunctive relief, specific performance, and other equitable relief to
prevent or restrain any Breach or threatened Breach of and to enforce specifically the terms and provisions of this
Agreement.
7.LIMITATION OF LIABILITY
Any provision in the Contract limiting Contractor’s liability shall not apply to Business Associate’s liability under
this Agreement, which shall not be limited.
8.DISCLAIMER
Covered Entity makes no warranty or representation that compliance by Business Associate with this Agreement
or the HIPAA Rules will be adequate or satisfactory for Business Associate’s own purposes. Business Associate
is solely responsible for all decisions made and actions taken by Business Associate regarding the safeguarding of
PHI.
9.CERTIFICATION
Covered Entity has a legal obligation under HIPAA Rules to certify as to Business Associate’s Information
Security practices. Covered Entity or its authorized agent or contractor shall have the right to examine Business
Associate’s facilities, systems, procedures, and records, at Covered Entity’s expense, if Covered Entity
determines that examination is necessary to certify that Business Associate’s Information Security safeguards
comply with the HIPAA Rules or this Agreement.
Exhibit D-1
Page 7 of 11 HIPAA BAA/QSOA
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10.AMENDMENT
a.Amendment to Comply with Law. The Parties acknowledge that state and federal laws and
regulations relating to data security and privacy are rapidly evolving and that amendment of this
Agreement may be required to provide procedures to ensure compliance with such developments.
i.In the event of any change to state or federal laws and regulations relating to data security
and privacy affecting this Agreement, the Parties shall take such action as is necessary to
implement the changes to the standards and requirements of HIPAA, the HIPAA Rules
and other applicable rules relating to the confidentiality, integrity, availability and
security of PHI with respect to this Agreement.
ii.Business Associate shall provide to Covered Entity written assurance satisfactory to
Covered Entity that Business Associate shall adequately safeguard all PHI, and obtain
written assurance satisfactory to Covered Entity from Business Associate’s
Subcontractors and agents that they shall adequately safeguard all PHI.
iii.Upon the request of either Party, the other Party promptly shall negotiate in good faith the
terms of an amendment to the Contract embodying written assurances consistent with the
standards and requirements of HIPAA, the HIPAA Rules, or other applicable rules.
iv.Covered Entity may terminate this Agreement upon 30 days’ prior written notice in the
event that:
A.Business Associate does not promptly enter into negotiations to amend the Contract
and this Agreement when requested by Covered Entity pursuant to this Section; or
B.Business Associate does not enter into an amendment to the Contract and this
Agreement, which provides assurances regarding the safeguarding of PHI sufficient,
in Covered Entity’s sole discretion, to satisfy the standards and requirements of the
HIPAA, the HIPAA Rules and applicable law.
b.Amendment of Appendix. The Appendix to this Agreement may be modified or amended by the
mutual written agreement of the Parties, without amendment of this Agreement. Any modified or
amended Appendix agreed to in writing by the Parties shall supersede and replace any prior version
of the Appendix.
11.ASSISTANCE IN LITIGATION OR ADMINISTRATIVE PROCEEDINGS
Covered Entity shall provide written notice to Business Associate if litigation or administrative proceeding is
commenced against Covered Entity, its directors, officers, or employees, based on a claimed violation by
Business Associate of HIPAA, the HIPAA Rules or other laws relating to security and privacy or PHI. Upon
receipt of such notice and to the extent requested by Covered Entity, Business Associate shall, and shall cause its
employees, Subcontractors, or agents assisting Business Associate in the performance of its obligations under the
Contract to, assist Covered Entity in the defense of such litigation or proceedings. Business Associate shall, and
shall cause its employees, Subcontractor’s and agents to, provide assistance, to Covered Entity, which may
Exhibit D-1
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include testifying as a witness at such proceedings. Business Associate or any of its employees, Subcontractors or
agents shall not be required to provide such assistance if Business Associate is a named adverse party.
12.INTERPRETATION AND ORDER OF PRECEDENCE
Any ambiguity in this Agreement shall be resolved in favor of a meaning that complies and is consistent with the
HIPAA Rules. In the event of an inconsistency between the Contract and this Agreement, this Agreement shall
control. This Agreement supersedes and replaces any previous, separately executed HIPAA business associate
agreement between the Parties.
13.SURVIVAL
Provisions of this Agreement requiring continued performance, compliance, or effect after termination shall
survive termination of this contract or this agreement and shall be enforceable by Covered Entity.
Exhibit D-1
Page 9 of 11 HIPAA BAA/QSOA
Revised August 2018
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APPENDIX TO HIPAA BUSINESS ASSOCIATE AGREEMENT
This Appendix (“Appendix”) to the HIPAA Business Associate Agreement (“Agreement”) is s an appendix to the
Contract and the Agreement. For the purposes of this Appendix, defined terms shall have the meanings ascribed
to them in the Agreement and the Contract.
Unless the context clearly requires a distinction between the Contract, the Agreement, and this Appendix, all
references to “Contract” or “Agreement” shall include this Appendix.
1.PURPOSE
This Appendix sets forth additional terms to the Agreement. Any sub-section of this Appendix marked as
“Reserved” shall be construed as setting forth no additional terms.
2.ADDITIONAL TERMS
a.Additional Permitted Uses. In addition to those purposes set forth in the Agreement, Business
Associate may use PHI for the following additional purposes:
i.Reserved.
b.Additional Permitted Disclosures. In addition to those purposes set forth in the Agreement, Business
Associate may disclose PHI for the following additional purposes:
i.Reserved.
c.Approved Subcontractors. Covered Entity agrees that the following Subcontractors or agents of
Business Associate may receive PHI under the Agreement:
i.Reserved.
d.Definition of Receipt of PHI. Business Associate’s receipt of PHI under this Contract shall be
deemed to occur, and Business Associate’s obligations under the Agreement shall commence, as
follows:
i.Reserved.
e.Additional Restrictions on Business Associate. Business Associate agrees to comply with the
following additional restrictions on Business Associate’s use and disclosure of PHI under the
Contract:
i.Reserved.
ii.The Associate:
A.Acknowledges this agreement qualifies as a Qualified Service Organization
Addendum as the agreement is between a Substance Abuse Program
(“Program”) and a Qualified Service Organization as defined by 42 C.F.R.
Part 2.
Exhibit D-1
Page 10 of 11 HIPAA BAA/QSOA
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B.Acknowledges that in receiving, transmitting, transporting, storing,
processing or otherwise dealing with any information received from the
Program identifying or otherwise relating to the patient in the Program
(“protected information”), it is fully bound by the provisions of the federal
regulations governing the Confidentiality of Alcohol and Drug Abuse Patient
Records, 42 C.F.R. Part 2. Protected information encompasses protected
health information (“PHI”) and references to PHI shall be understood to
include protected information.
C.Agrees to resist any efforts in judicial proceeding to obtain access to the
protected information except as expressly provided for in the regulations
governing the Confidentiality of Alcohol and Drug Abuse patient Records,
42 C.F.R. Part 2.
D.Agrees that if the Associate enters into a contract with any agent or
subcontractor, the agent or subcontractor will agree to comply with 42 C.F.R
Part 2.
E.Agrees to ensure that any agent or subcontractor to whom the Associate
provides protected information received from the Program, or creates or
receives on behalf of the Program, agrees to the same restrictions and
conditions that apply through this agreement to the Associate with respect to
such information.
F.Agrees that redisclosure of protected information is prohibited unless
permitted by 42 C.F.R. Part 2.
f.Additional Terms. Business Associate agrees to comply with the following additional terms under the
Agreement.
i.Reserved.
Exhibit D-1
Page 11 of 11 HIPAA BAA/QSOA
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