HomeMy WebLinkAboutDoc 686 - ABHA IGA - Mental Health SvcsDeschutes County Board of Commissioners
1300 NW Wall St., Suite 200, Bend, OR 9770 1 -1 960
(541) 388 -6570 - Fax (541) 385 -3202 - www.deschutes.org
AGENDA REQUEST & STAFF REPORT
For Board Business Meeting of December 30, 2009
Please see directions for completing this document on the next page.
DATE: December 16, 2009
FROM: Nancy England, Contract Specialist Phone: 322 -7516
Health Services -- Behavioral Health Division
TITLE OF AGENDA ITEM:
Consideration of Board Signature of Document #2009 -686, an Intergovernmental Agreement
between Accountable Behavioral Health Alliance (ABHA) and Deschutes County Health Services.
PUBLIC HEARING ON THIS DATE? No
BACKGROUND AND POLICY IMPLICATIONS:
Deschutes County is one of five (5) counties who operate an organization titled Accountable
Behavioral Health Alliance (ABHA). ABHA is a behavioral health (managed care) organization
that manages federal Medicaid funds and assures behavioral health services to members of the
Oregon Health Plan (OHP) residing in five (5) Oregon counties including Deschutes County.
The contract for 2009 through 2014 assures that the State of Oregon will provide federal Medicaid
funds to ABHA. Funds will be used by Deschutes County and other providers for authorized
behavioral health services for OHP members in our county.
FISCAL IMPLICATIONS:
Maximum compensation of estimated at $17.5 million for a period of five years.
RECOMMENDATION & ACTION REQUESTED:
Behavioral Health requests approval.
ATTENDANCE: Nancy England, Contract Specialist
DISTRIBUTION OF DOCUMENTS:
Executed copies to:
Nancy England, Contract Specialist, Health Services
Capitation payments estimated at $17.5 million for the
DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: This form is required to be submitted with ALL contracts and other agreements,
regardless of whether the document is to be on a Board agenda or can be signed by the County
Administrator or Department Director. If the document is to be on a Board agenda, the Agenda
Request Form is also required. If this form is not included with the document, the document will
be returned to the Department. Please submit documents to the Board Secretary for tracking
purposes, and not directly to Legal Counsel, the County Administrator or the Commissioners. In
addition to submitting this form with your documents, please submit this form electronically to
the Board Secretary.)
Date:
Please complete all sections above the Official Review line.
December 2, 2009
Department:
Health Services, Behavioral Health
Contractor /Supplier /Consultant Name:
Contractor Contact:
Accountable Behavioral Health Alliance (ABHA)
Seth Bernstein, Ph.D.
Contractor Phone #:
Type of Document: Intergovernmental Agreement
541- 753 -8997
Goods and/or Services: Consideration and signature of document number 2009-686,
Agreement between Accountable Behavioral Health Alliance (ABHA) and Deschutes County
Health Services (DCHS).
Background & History: Deschutes County is one of five (5) counties who operate an
organization titled Accountable Behavioral Health Alliance (ABHA). ABHA is a behavioral health
(managed care) organization that manages federal Medicaid funds and assures behavioral
health services to members of the Oregon Health Plan (OHP) residing in five (5) Oregon
counties including Deschutes County.
The contract for year 2009 through 2014 assures that the State of Oregon will provide federal
Medicaid funds to ABHA. Funds will be used by Deschutes County and other providers for
authorized behavioral health services for OHP members in our county.
Agreement Starting Date:
August 1, 2009
Annual Value or Total Payment:
period of five years
Ending Date:
August 31, 2014
® Insurance Certificate Received (check box)
Insurance Expiration Date:
County is Contractor
Check all that apply:
❑ RFP, Solicitation or Bid Process
❑ Informal quotes ( <$150K)
Z Exempt from RFP, Solicitation or Bid Process (specify — see DCC §2.37)
Funding Source: (Included in current budget? ® Yes ❑ No
12/2/2009
If No, has budget amendment been submitted? ❑ Yes ❑ No
Is this a Grant Agreement providing revenue to the County? ❑ Yes ® No
Special conditions attached to this grant:
Deadlines for reporting to the grantor:
If a new FTE will be hired with grant funds, confirm that Personnel has been notified that it is a
grant - funded position so that this will be noted in the offer letter: ❑ Yes ❑ No
Contact information for the person responsible for grant compliance: Name:
Phone #:
Departmental Contact and Title:
Phone #:
541 - 322 -7516
Department Director Approval:
Nancy England, Contract Specialist
12.2
Date
Distribution of Document: Return both originals to Nancy England, Mental Health
Department.
Official Review:
County Signature Required (check one): I I BOCC ❑ Department Director (if <$25K)
❑ Administrator (if >$25K Tt <$150K; if >$150K, BOCC Order No. )
Legal Review i Date %z - % v j
Document Number 2009 -686
12/2/2009
REVIEWED
LEGAL COUNSEL
INTERGOVERNMENTAL AGREEMENT BETWEEN
ACCOUNTABLE BEHAVIORAL HEALTH ALLIANCE
AND DESCHUTES COUNTY
This Agreement (the "Agreement ") is made and entered into by and between DESCHUTES
COUNTY, a political subdivision of the State of Oregon, (hereinafter called "CONTRACTOR ")
and Accountable Behavioral Health Alliance ( "ABHA "), which was formed by and is
comprised of ABHA and its member counties (Benton, Deschutes, Crook, Jefferson, and. Lincoln
Counties collectively "Member Counties ") with reference to the following facts:
RECITALS
WHEREAS, ABHA is an Oregon ORS (Oregon Revised Statutes) Chapter 190
Intergovernmental Entity that has as its primary objective to arrange for and facilitate the
provision and delivery of Behavioral Health Services to persons enrolled in the Oregon Health
Plan and assigned to ABHA or who are covered by intergovernmental agreements with ABHA
( "Member ").
WHEREAS, CONTRACTOR and ABHA desire to enter into this Agreement
NOW, THEREFORE, the parties hereby agree as follows:
1.0 DEFINITIONS: Definitions relevant to this contract are listed in Attachment B.
2.0 TERM OF AGREEMENT. This Agreement shall become effective on August 1, 2009
and shall have a term of five (5) years unless terminated sooner pursuant to the terms of
Section 13. This Agreement supersedes and replaces all existing ABHA contracts with
CONTRACTOR covering services listed in Attachment A -1 and Subcontracted Activities
and responsibilities listed in Attachment A -2.
3.0 SERVICES TO BE PROVIDED
3.1 CONTRACTOR shall provide Services to Oregon Health Plan (OHP) Members,
herein called Members, of ABHA as outlined in Attachment(s) A -1 through A -3.
3.1.1 If CONTRACTOR subcontracts all or part of the Services and /or
subcontracted activities of this Agreement , CONTRACTOR remains
responsible for all terms and conditions of this Agreement.
3.1.1.1 CONTRACTOR's agreement with subcontractor shall incorporate
all applicable terms and conditions of this Agreement between
ABHA and CONTRACTOR.
3.1.2 When CONTRACTOR refers members to an ABHA Panel Provider for
any services specified in Attachment A -1, it is doing so in lieu of
providing these services through CONTRACTOR's clinical staff.
CONTRACTOR shall follow procedures of the ABHA Utilization
Management Plan, as currently in effect or as may be amended from time
to time by ABHA.
3.1.2.1 ABHA shall enter into contracts with panel providers on behalf of
the CONTRACTOR, as outlined in the ABHA Utilization
Management Plan.
De - 2009-684
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 1 of 25
3.2 In the event Service to a Member is interrupted or discontinued due to provider
illness, retirement, etc, CONTRACTOR will inform the Member and /or Member
representative in a clinically appropriate manner both in person and in writing and
as far in advance of such a change as possible. CONTRACTOR will take steps
needed to assure that its Member's clinical needs are addressed and that the
Member is transitioned in a professional manner to an appropriate provider.
Referrals will be made in consultation with ABHA and in a manner consistent
with the ABHA Utilization Management Plan.
3.3 CONTRACTOR shall coordinate the provision of mental health services with
physical health care providers, chemical dependency providers, Fully Capitated
Health Plans (FCHPs);Chemical Dependency Organizations (CDOs) and
Medicare providers.
4.0 PAYMENT
4.1 ABHA shall issue a monthly sub - capitated payment to CONTRACTOR based on
the number and type of eligible and enrolled ABHA Members of the Oregon
Health Plan that are residents of CONTRACTOR's county. Payment will be
based on the provision of Services and Subcontracted Activities described in
Attachments A -1 and A -2 respectively. Monthly amounts will vary as ABHA
membership in CONTRACTOR's county changes from month to month. .
ABHA shall provide CONTRACTOR a monthly report which clearly sets forth
the difference, if any, between the capitated payment remitted to CONTRACTOR
by ABHA, compared to the total received by ABHA on- behalf of
CONTRACTOR's eligible OHP population. ABHA's monthly payment to
CONTRACTOR will be issued with a Remittance Advice to CONTRACTOR by
the 25th of each month.
4.2 Other funds, as approved by the ABHA Governing Board, may be issued to
CONTRACTOR. All funds received under this Agreement can only be used to
provide and /or support the provision of services that have a benefit to ABHA
Members. This restriction applies to both funding received during each budget
year and reserves that may accrue.
4.3 CONTRACTOR will submit claims electronically in HIPAA- compliant (Health
Insurance Portability and Accountability Act of 1996) format to ABHA's
Third Party Administrator (TPA) in accordance with HIPAA regulations.
CONTRACTOR must submit Capitated Claims at least once per calendar month.
The Capitated Claims must represent at least 50% of all claim types (professional
and institutional) received and adjudicated by CONTRACTOR for the preceding
month. CONTRACTOR may have another TPA submit Capitated Claims on its
behalf. CONTRACTOR shall coordinate with ABHA's TPA regarding claim
submittal and shall remain responsible for Capitated Claims data accuracy,
timeliness and completeness regardless of the entity submitting the Capitated
Claims.
4.4 CONTRACTOR must determine its Billable Charges based upon reasonable and
customary costs of services in accordance with a cost allocation plan, OMB
Circular A -87 or A -122, or other applicable state and federal laws, rules and
regulations, but not in excess of the CONTRACTOR's usual and customary
charges to the general public. Charges should reflect the cost of the service
performed. CONTRACTOR will update unit costs at least annually using the
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 2 of 25
most current version of the Unit Cost Calculator tool. As specified in the Mental
Health Organization (MHO) Agreement and ABHA's Third Party Resources
Policy, for any given service, CONTRACTOR'S Billable Charge shall not exceed
the reasonable and customary amount charged to patients who are not Members.
5.0 WAIVER. If any aspect of this Agreement shall be found to be illegal or invalid for any
reason, such illegality or invalidity shall not affect the validity of the remainder of this
Agreement .
6.0 COLLECTION OF CHARGES FROM MEMBERS. CONTRACTOR shall in no
event, including but not limited to, insolvency of ABHA, or breach of this Agreement,
bill, charge, collect a deposit, or attempt to bill, charge, collect or receive any form of
payment from any Member for Mental Health Services provided pursuant to this
Agreement other than co- payments, deductibles, or other charges required and specified
by the Department of Medical Assistance Programs (DMAP) under the Oregon Health
Plan.
Except as provided in Section 7.0, CONTRACTOR shall not maintain any action at law
or equity against a member to collect sums owed by ABHA to CONTRACTOR. Upon
notice of any such action or charge, ABHA may terminate this Agreement and take all
other appropriate action consistent with the terms of this Agreement (Section 12) to
eliminate such charges, including requiring CONTRACTOR to return all sums collected
by CONTRACTOR as surcharges from Members or their representatives. Nothing in
this Agreement, however, shall be construed to prevent CONTRACTOR from providing
non - covered health care services on a usual and customary fee - for - service basis to
Members.
CONTRACTOR'S obligations under this Section shall survive the termination of this
Agreement with respect to mental health services provided during the term of the
Agreement without regard to cause of termination of the Agreement.
7.0 COLLECTION OF CHARGES FROM THIRD PARTIES. CONTRACTOR accepts
payment from ABHA in the form of capitation for mental health services provided herein
as full payment for such services. However, in the event of third party liability, worker's
compensation claims, or other primary insurance coverage maintained by Member,
CONTRACTOR shall be entitled to all reimbursement received from third parties,
workers compensation, primary insurance, or similar third party resources of payment for
these mental health services. Such payment is considered primary to any payment
obligation of ABHA and must be billed prior to submitting Capitated Claims to ABHA's
TPA. On a quarterly basis, CONTRACTOR shall report to ABHA any funds or denials
received from third party resources using the form required for such reporting by the
MHO Agreement.
8.0 STATUS OF CONTRACTOR.
The parties intend that CONTRACTOR, in performing the services specified in this
agreement, shall act as an independent contractor and shall have the control of the work
and the manner in which it is performed. CONTRACTOR is not to be considered an
agent or employee of ABHA and is not entitled to participate in any pension plan,
insurance, bonus, or other benefits ABHA provides its employees.
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 3 of 25
9.0 INDEMNIFICATION.
ABHA has relied upon the professional ability and training of CONTRACTOR as a
material inducement to enter into this agreement. CONTRACTOR warrants that its work
will be performed in accordance with generally accepted professional practices and
standards as well as the requirements of applicable federal, state and local laws, it being
understood that acceptance of CONTRACTOR'S work by ABHA shall not operate as a
waiver or release.
The parties also agree, that pursuant to the limits of the Oregon Tort Claims Act, each
party shall hold harmless, indemnify, and defend the other party, its officers, agents and
employees from any and all liability, actions, claims, losses, damages, or other costs that
may be asserted by any person or entity arising from, during, or in connection with the
performance of the work described in this Agreement, for the actions of the party, or the
party's own officers, agents and employees. This indemnification, defense and hold
harmless shall include attorney's fees and witness costs that arise in preparation for or in
the course of an administrative process, trial or appeal, whether or not a hearing, trial, or
appeal ever takes place. Such indemnification shall include without limitation claims
brought against either party under state or federal laws. Notwithstanding the above,
neither party shall have any duty to indemnify, defend or hold harmless the other party
for liability, actions, claims, losses, damages, or other costs that are asserted or arise
solely from the negligence of the other party
10.0 INSURANCE. CONTRACTOR shall purchase and maintain, at CONTRACTOR's
expense, insurance covering the CONTRACTOR, Coverage must include:
10.1 Commercial general liability insurance covering personal injury and property
damage with a combined single limit, or the equivalent of not less than
$1,000,000 subject to limits of liability provided in the Oregon Tort Claims Act
(ORS 30.260- 30.300) as may be amended from time to time. This insurance shall
include contractual liability coverage for the indemnity provided under this
agreement. The CONTRACTOR's policy must specifically include coverage for
sexual abuse and molestation. The coverage for sexual abuse and molestation
will have a $250,000 each occurrence, $500,000 aggregate limit. Evidence of the
inclusion of sexual abuse and molestation coverage and the limits of that
coverage, in the form of an insurance certificate, must be provided to ABHA prior
to the execution of an Agreement. CONTRACTOR will be required to certify that
it has performed criminal background checks for any employees, volunteers, or
other representatives who will have contact with Members. This policy shall
provide by separate endorsement that ABHA, its officers and employees; and
ABHA county subcontractors, their officers, agents and employees' are named as
Additional Insureds, but only with respect to the CONTRACTOR's services to be
provided under this Agreement.
10.2 Professional Liability Insurance with a combined single limit of not less than
$1,000,000 each claim, incident or occurrence. This is to cover damages
allegedly caused by error, omission or negligent acts related to the professional
services to be provided under this Agreement.
ABHA county subcontractors include Benton, Crook, Deschutes, Jefferson, and Lincoln Counties
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 4 of 25
10.3 Worker's Compensation Insurance in compliance with 656.017, which requires
subject employers to provide Oregon workers compensation coverage for all their
subject workers.
10.4 CONTRACTOR may satisfy any of the requirements of this section through a
program of self - insurance as provided in ORS 30.282
10.5 A copy of the policy or Certificate(s) of Insurance acceptable to ABHA shall be
filed with the ABHA prior to the effective date of this contract. The policy or
certificate shall provide for thirty days notice of cancellation or material change.
11.0 METHOD AND PLACE OF GIVING NOTICE, SUBMITTING ENCOUNTER
DATA AND MAKING PAYMENTS. All notices shall be made in writing and may be
given by personal delivery or by mail. Notices, sent by mail should be addressed as
follows:
CONTRACTOR: DESCHUTES COUNTY
2577 NE Courtney Drive
Bend, OR 97701
ABHA:
Accountable Behavioral Health
Alliance
310 NW 5th Street, Suite 206
Corvallis, Oregon 97330
PhTech / Encounter Data (503) 584-
2151 (fax (503) 566 -9801)
Phone: (541) 322 -7500
FAX: (541) 322 -7565
(541) 753 -8997 (Main
Phone)
(541) 752 -4877 (FAX)
And when so addressed, shall be deemed given upon deposit in the United States mail,
postage prepaid. In all other instances, notices, bills, and payments shall be deemed
given at the time of actual delivery. Changes in contact information are to be given by
providing notice pursuant to this paragraph.
12.0 Successors in Interest <NOTE; THIS LANGUAGE REPLACES THE `MERGER'
SECTION' AND COMES DIRECTLY FROM THE MHO AGREEMENT>
12.1 CONTRACTOR shall not assign or transfer any of its interest in this Agreement
without the prior written consent of ABHA. Subject to the immediately preceding
sentence, the provisions of this Agreement shall be binding upon and shall inure
to the benefit of the parties hereto, and their respective successors and permitted
assigns, if any. In addition to any other assignment or transfer of interest, for
purposes of this Agreement, all of the following fundamental changes shall be
considered an assignment of an interest in this Agreement subject to ABHA prior
written consent.
a. A consolidation or merger of CONTRACTOR, or of a corporation or other
entity or person controlling or controlled by CONTRACTOR, with or into a
corporation or entity or person, or any other reorganization or transaction or
series of related transactions involving the transfer of more than 50% of the
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 5 of 25
equity interest in CONTRACTOR or more than 50% of the equity interest in 11 .
corporation or other entity or person controlling or controlled by
CONTRACTOR, or
b. The sale, conveyance or disposition of all or substantially all of the assets of
CONTRACTOR, or of a corporation or other entity or person controlling or
controlled by CONTRACTOR, in a transaction or series of related
transactions.
12.2 CONTRACTOR shall notify ABHA at least forty -five (45) calendar days prior to
any assignment or transfer of an interest in this Agreement.
13.0 TERMINATION.
13.1 Termination of this Agreement without Cause. Either Party may terminate this
Agreement without cause at any time by providing at least one hundred and
eighty (180) days prior written notice of termination to the other Party. If either
party terminates the Agreement pursuant to this paragraph, ABHA shall pay
CONTRACTOR for services rendered up to and including the date of termination.
13.2 Termination with Cause. Either party may terminate this Agreement for cause by
providing thirty (30) days prior written notice of termination to the other party.
Such notice of termination shall state the circumstances constituting cause for
termination.
a. "Cause" means breach of any material term or condition of this Agreement
that is not cured within thirty (30) days of receipt of written notice.
b. ABHA will notify CONTRACTOR in writing at the end of the 30 day period
regarding its evaluation of CONTRACTOR'S efforts to take corrective
actions which remedy the circumstance which led to ABHA's termination
notice.
i. ABHA, at its sole discretion, may elect to extent the remedy period
beyond 30 days
c. CONTRACTOR will notify ABHA in writing at the end of the 30 day period
regarding its evaluation of ABHA' S efforts to take corrective actions which
remedy the circumstance which led to CONTRACTOR'S termination notice.
ii. CONTRACTOR, at its sole discretion, may elect to extent the remedy
period beyond 30 days
13.3 Remedies Short of Termination
a. Whenever ABHA, in its sole judgment, determines that CONTRACTOR is
not fulfilling the terms of this Agreement, ABHA may, at its discretion,
require Remedial Action of the CONTRACTOR. ABHA shall issue a Notice
of Intended Remedial Action which provides, in non - Emergency Situations, at
least thirty (30) calendar days' notice prior to the effective date of the
Remedial Action, and in Emergency Situations, at least seven (7) calendar
days' notice prior to the effective date of Remedial Action.
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 6 of 25
b. Remedial Action provides for a range of options of varying severity
depending on the seriousness and nature of the Agreement violation. Options
include suspension of Agreement, financial withholds, or other sanctions
designed to remedy the requirements of this Agreement that are not being
fulfilled. Such requirements include, but are not limited to the following:
i. Failure to provide medically appropriate Services that are required to
be provided to OHP Members under this Agreement;
ii. CONTRACTOR acts to discriminate among OHP Members on the
basis of their mental health status or need for mental health Services;
iii. Misrepresentation or falsification of information that CONTRACTOR
provides to an OHP Member or OHP Member Representative,
Potential Enrollee, Provider, Centers for Medicare and Medicaid
(CMS) or the Oregon Department of Human Services (DHS);
iv. Failure to comply with fraud and abuse requirements;
v. Violation of any of the other applicable requirements of sections
1903(m) or 1932 of the Social Security Act and any implementing
regulations.
vi. Failure to provide Services and perform Subcontracted Activities and
responsibilities as described in Attachments A -1, A -2, and A -3.
c. CONTRACTOR may request a review concerning the Notice of Intended
Remedial Action and may also request suspension of the Remedial Action
until a decision is reached through a review process. It is ABHA's intention to
work cooperatively with CONTRACTOR to remedy performance problems.
Invoking the termination provisions of this Agreement will only be done after
other attempts have failed. The terms of this section of the Agreement will
only be invoked with the express consent of ABHA's Governing Board.
14.0 NON - DISCRIMINATION IN TREATMENT OF CONSUMERS BY
CONTRACTOR. CONTRACTOR shall not discriminate against Members in violation
of any local, state or federal law with respect to care and shall provide services to
Members in the same manner, in accordance with the same standards and within the same
time availability as those services are provided to CONTRACTOR's other clients.
CONTRACTOR shall not discriminate in the care or quality of services on the basis of
age, race, religion, color, sex, marital status, familial status, national origin, age, mental
or physical disability, sexual orientation, source of income, or political affiliation.
15.0 COMPLIANCE WITH APPLICABLE LAWS AND LICENSES.
CONTRACTOR shall comply with all applicable federal, state or local laws, rules and
regulations applicable to the work performed under this Agreement. CONTRACTOR
shall comply with all applicable standards of professional ethics and shall perform
services within the scope of CONTRACTOR's licenses.
CONTRACTOR will adhere to and comply with all provisions of the False Claims Act
established under sections 3729 through 3733 of title 31, United States Code,
administrative remedies for false claims and statements established under chapter 38 of
title 31, United States Code, any Oregon laws pertaining to civil or criminal penalties for
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 7 of 25
false claims and statements, and whistleblower protections under such laws, with respect
to the role of such laws in preventing and detecting fraud, waste, and abuse in Federal
health care programs (as defined in 42 USC 1320a -7b.
CONTRACTOR shall have in place internal controls, quality assurance processes,
policies or procedures capable of preventing and detecting fraud and abuse activities as
they relate to the OHP and taking corrective actions.
16.0 CERTIFICATION AND CREDENTIALING. CONTRACTOR will provide
documentation of State certification and /or State licensure for all services provided as
outlined in Attachment A -1. Credentialing will be conducted in a manner that is
consistent with ABHA's Credentialing Policy and Procedure and the requirements of
ABHA's Mental Health Organization (MHO) Agreement with the State of Oregon.
17.0 CREDENTIALING: All CONTRACTOR'S employees providing direct Mental Health
Services under this Agreement must be credentialed prior to service delivery or the
CONTRACTOR receiving reimbursement for services. CONTRACTOR will ensure that
all employees performing services under this agreement are credentialed in a manner
consistent with the ABHA Credentialing Policy, which is hereby incorporated by
reference. This policy, which includes the requirements to verify positive clearance from
the National Practitioners Data Bank; Office of Inspector General's Exclusions list; and
GSA's Excluded Parties List System, shall additionally apply to persons or entities who
are subcontractors.
17.1 CONTRACTOR shall make available to ABHA upon request, credentialing files
of employees performing work under this Agreement.
18.0 CONFIDENTIALITY AND HIPAA PROVISIONS: CONTRACTOR and ABHA
agree to hold all individually identifiable patient health information ( "Protected Health
Information ") that may be shared, transferred, transmitted, or otherwise obtained pursuant
to this Agreement strictly confidential, and provide all reasonable protections to prevent
the unauthorized use or disclosure of such information, including, but not limited to the
protection afforded by applicable federal, state and local laws and/or regulations
regarding the security and the confidentiality of patient health care information. The
parties further agree to make every reasonable effort to comply with any regulations,
standards, or rules promulgated pursuant to the authority of the Health Insurance
Portability and Accountability Act of 1996 ( "HIPAA "), including those provision listed
below, as soon as possible, but in no event later than the mandatory HIPAA compliance
date. The parties may use and disclose Protected Health Information when necessary for
CONTRACTOR'S proper management and administration (if such use or disclosure is
necessary), or to carry out CONTRACTOR'S specific legal responsibilities pursuant to
this Agreement.
19.0 MAINTENANCE OF RECORDS. Upon 30 day written notice and at an agreed upon
date and time, CONTRACTOR shall provide (subject to the provisions of Section 18.0
above) to ABHA or any governmental agency with regulatory authority over
CONTRACTOR or ABHA, access to all Member patient records and other information
relating to Behavioral Health Services provided to Members, in such form and containing
such information as required by applicable state law (and in accordance with usual and
customary practices in the United States), including medical and behavioral health
histories, records and reports from other providers, discharge summaries, and such other
information as ABHA, or other governmental agency may require. CONTRACTOR
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 8 of 25
shall maintain such records for the greater of six (6) years or the length of time
CONTRACTOR is required to maintain patient records under applicable state law.
20.0 CONFLICT OF INTEREST as defined by ORS Chapter 244. CONTRACTOR shall
comply with the ABHA Conflict of Interest Policy, which is incorporated by reference.
21.0 AUDIT. CONTRACTOR shall maintain records to assure conformance with the terms
and conditions of this Agreement, and to assure adequate performance and appropriate
expenditures within the term of this Agreement. CONTRACTOR agrees to permit
ABHA, the State of Oregon, the federal government, or their duly authorized
representatives, upon reasonable notice, to audit all records pertaining to this Agreement
to assure compliance with the terms of this Agreement
22.0 DISPUTE RESOLUTION. The parties agree that any dispute or claim that arises out of
or relates to this Agreement, or to the interpretation or breach of this Agreement, shall be
resolved by arbitration in accordance with the then existing rules of the Arbitration
Service of Portland, Inc., and judgment upon the award rendered to such arbitration may
be entered in any court having jurisdiction over this Agreement. The parties
acknowledge that mediation usually helps parties resolve their disputes; therefore, any
party may propose mediation whenever appropriate through the Arbitration Service of
Portland, Inc., or through Community Mediation Services of DESCHUTES COUNTY, or
any other mediation process or mediation the parties may agree upon.
23.0 VENUE, JURISDICTION AND APPLICABLE LAW. The venue for any action
arising out of or relating to this agreement shall be in DESCHUTES COUNTY, Oregon.
Any court action arising out of or relating to this agreement shall be filed in the Circuit
Court of DESCHUTES COUNTY, Oregon. The applicable laws for any action arising
out of or relating to this agreement shall be the laws of the State of Oregon.
CONTRACTOR specifically agrees to abide by applicable provisions of ORS 279 A, B,
or C, incorporated by this reference.
24.0 SERVICE INTEGRATION. The CONTRACTOR shall use its best efforts to obtain
signed releases and /or authorizations consistent with state and Federal and other
applicable privacy and security standards, including HIPAA, from all ABHA referred
members and submit documentation of services provided under this Agreement to
Member's Primary Care Physician (PCP) and /or other clinician providing health services
related to the Member's mental health condition within thirty (30) days of service for
inclusion in the Member's medical record.
25.0 MEMBER ELIGIBILITY. CONTRACTOR must verify Member's eligible status as an
ABHA Member at time of each service. ABHA shall only provide reimbursement for
Members who are enrolled with ABHA on the date of service delivery.
26.0 MEMBER NOTICE, GRIEVANCES AND APPEALS. CONTRACTOR shall follow
ABHA's policy and procedure for resolution of Member's grievances and appeals.
ABHA's policies and procedures are incorporated by reference into this agreement. The
ABHA Utilization Management Plan, which includes ABHA's policy and procedure
regarding OHP Member Grievance, Appeal and Hearing Process, is incorporated into this
contract by reference.
CONTRACTOR shall follow ABHA's policy and procedure for Notice of Action to
Members when CONTRACTOR reduces, denies, suspends or terminates services without
the Member's expressed concurrence. This policy is also a part of the ABHA Utilization
Management Plan.
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 9 of 25
27.0 PARTICIPATION IN QUALITY ASSURANCE, UTILIZATION REVIEW, AND
PEER REVIEW. CONTRACTOR shall participate in such Utilization Review, Peer
Review, and Quality Management programs that ABHA, including ABHA staff and /or
the county mental health staff of ABHA member counties, may deem necessary to
improve the quality of clinical services and /or to contain or reduce medical costs without
compromising mental health care. The ABHA Quality Management and Utilization
Management Plans are incorporated by reference into this agreement
CONTRACTOR will have processes in place that are designed to assure that Clinical
Services are provided in a manner that is consistent with best practices, practice
guidelines and evidence -based practices. Such activities will also be designed to assure
that such services are provided in compliance with the applicable state and federal laws
and regulations.
CONTRACTOR shall participate in the ABHA Outcome Measurement Program, which
is a component of its Quality Management Program.
CONTRACTOR will have a process for the investigation of critical incidents.
28.0 ACCESS TO RECORDS AND FACILITIES: CONTRACTOR shall provide access to
records and facilities as described in Oregon Administrative Rule (OAR) 410 - 141 -0180,
Oregon Health Plan Prepaid Health Plan Record keeping. CONTACTOR shall cooperate
with ABHA, its county members, and the Department of Addictions and Mental Health
(AMH) of the State of Oregon in medical and financial record reviews, contract
compliance and quality assurance monitoring. Upon 30 day written notice and at an
agreed upon date and time, CONTRACTOR shall ensure that such records are available
at the request of ABHA, its county members, or AMH without cost and within the
applicable laws or regulatory standards protecting confidentiality.
29.0 MEMBER RIGHTS AND RESPONSIBILITIES: The ABHA Member Handbook
describes Member rights and responsibilities as well as the process by which ABHA
Members access treatment. It is incorporated into this contract by reference. At initial
face to face contact, CONTRACTOR will review member rights and responsibilities with
the Member and make notation in the clinical record. CONTRACTOR shall post OHP
Member rights in a visible location in all service locations.
30.0 MISCELLANEOUS FEDERAL AND STATE REQUIREMENTS.
30.1 The MHO Agreement, which is signed annually by each county and amended as
required by the State, is incorporated into this contract by reference. The
requirements of the MHO Agreement are binding on all parties and when in
conflict with the terms of conditions of this Agreement, will take precedence
30.2 The CONTRACTOR certifies, to the best of its knowledge and belief, that:
30.2.1 No federal appropriated funds have been paid or will be paid by or on
behalf of CONTRACTOR, to any person for influencing or attempting to
influence any officer or employee of any agency, a member of Congress,
an officer or employee of Congress, or an employee of a member of
Congress in connection with the awarding of any federal contract, the
making of any federal grant, the making of any federal loan, the entering
into of any cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of any federal contract, grant, loan,
or cooperative agreement.
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 10 of 2E
30.2.2 If any funds other than federal appropriated funds have been paid or will
be paid to any person for influencing or attempting to influence an officer
or employee of any agency, a member of Congress, an officer or employee
of Congress, or an employee of Congress in connection with this federal
contract, grant, loan, or cooperative agreement, CONTRACTOR agrees to
complete and submit Standard Form -LLL "Disclosure Form to Report
Lobbying ", in accordance with its instructions.
30.2.3 CONTRACTOR is solely responsible for all liability arising from a failure
by CONTRACTOR to comply with the terms of this certification.
Additionally, CONTRACTOR promises to indemnify ABHA for any
damages suffered by ABHA as a result of CONTRACTOR'S failure to
comply with the terms of this certification.
This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction imposed
by Section 1352, Title 31, and US Code. Any person who fails to file the required
certification shall be subject to a civil penalty of not less than $10,000 and not
more than $100,000 for each such failure.
30.3 Financial Risk, Management and Solvency
30.3.1 CONTRACTOR shall assume the risk for providing Services outlined in
Attachment A -1 to its OHP Members. CONTRACTOR shall provide
assurances to ABHA that CONTRACTOR'S provision(s) against the risk
of Insolvency are adequate to ensure that OHP Members will not be liable
for CONTRACTOR'S debts if CONTRACTOR becomes insolvent.
CONTRACTOR shall maintain risk protection against catastrophic or
unexpected OHP Member expenses related to Covered Services, and shall
maintain protections against insolvency. If CONTRACTOR anticipates a
change to its solvency or to the effectiveness of its solvency protection
arrangements, CONTRACTOR shall provide written notice to ABHA
within 30 days.
30.3.2 CONTRACTOR must protect itself against loss by either self - insuring or
providing proof of Reinsurance and by maintaining a Restricted Reserve
Fund
30.3.3 CONTRACTOR shall maintain financial, medical and other records
pertinent to this Agreement. All financial records shall be maintained
pursuant to generally accepted accounting principles and other records
shall be maintained to the extent necessary to clearly reflect actions taken.
CONTRACTOR shall retain all records, other than medical records, for at
least 3 years after final payment is made under this Agreement or under
any subcontract and until all pending matters are closed. Additionally, if
an audit, litigation, or other action involving the records is started before
the end of the three -year period, the records must be retained until all
issues arising out of the action are resolved or until the end of the three -
year period, whichever is later. Medical records are to be maintained for
seven years. Retention of medical records is covered in OAR 410 -141-
0180, Medical Recordkeeping.
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 11 of 25
30.3.3.1 At all reasonable times, CONTRACTOR shall provide
Department of Medical Assistance Programs (DMAP), the
Department of Addictions and Mental Health (AMH), the Health
Care Financing Administration, the Comptroller General of the
United States, the Oregon Secretary of State, and all their duly
authorized representatives the right of access to its facilities.
Financial and medical records, which are directly pertinent to this
Agreement, will be provided by CONTRACTOR in order to
monitor and evaluate cost, performance, compliance, quality,
appropriateness, and timeliness of services provided under this
Agreement and the capacity of CONTRACTOR to bear the risk of
potential financial losses. These records shall be made available to
ABHA staff and /or member counties for the purpose of making
audit, examination, excerpts, and transcriptions. CONTRACTOR
shall, upon request and without charge, provide a suitable work
area and copying capabilities to facilitate such a review or audit.
30.3.4 Failure to maintain adequate financial Solvency, as determined by ABHA,
shall be grounds for termination of this Contract by ABHA.
30.3.5 In the event that Insolvency occurs, CONTRACTOR remains financially
responsible for providing Covered Services for OHP Members through the
end of the period for which CONTRACTOR has been paid,
30.4 CONTRACTOR shall comply with Title VI of the Civil Rights Act of 1964, the
Age Discrimination Act of 1975, Section V of the Rehabilitation Act of 1973, the
Americans with Disabilities Act of 1990 (ADA), and all amendments to those acts
and all regulations promulgated there under. CONTRACTOR shall also comply
with all applicable requirements of state civil rights and rehabilitation statutes and
rules.
30.5 If the sums payable to CONTRACTOR under this Agreement exceed $100,000,
CONTRACTOR shall comply with all applicable standards, orders or
requirements issued under Clean Air Act (codified at 42 USC 7401 et.seq.),
Federal Water Pollution Control Act, as amended (codified at 33 USC 1251 et.
seq.), Executive Order 11738, and Environmental Protection Agency (EPA)
regulations (40 CFR Part 15), which prohibit the use of facilities included on the
EPA List of Violating Facilities. Any violations shall be reported to ABHA, the
Department of Health and Human Services and to the U.S. EPA Assistant
Administrator for Enforcement (EN -329).
CONTRACTOR shall comply with all mandatory standards and policies that
relate to the Resource Conservation and Recovery Act (codified at 42 USC
6962). Section 6002 of that Act requires that preference be given in procurement
programs to the purchase of specific products containing recycled materials
identified in guidelines developed by the Environmental Protection Agency.
Current guidelines are contained in 40 CFR Parts 247 -253.
If the sums payable to CONTRACTOR exceed $10,000, CONTRACTOR shall
comply with Executive Order 11246, entitled "Equal Employment Opportunity ",
as amended by Executive Order 11375, and as supplemented in Department of
Labor regulations (41 CFR Part 60).
DESCHUTES COUNTY ! ABHA IGA 2009 -2014 Page 12 of 2!'
CONTRACTOR and any laboratories used by CONTRACTOR shall comply with
the Clinical Laboratory Improvement Amendments (CLIA 1988), which require
that:
All laboratory- testing sites providing services under this contract shall
have either a Clinical Laboratory Improvement Amendments (CLIA)
certificate of waiver or a certificate of registration along with a CLIA
identification number. Those laboratories with certificates of waiver will
provide only the eight types of tests permitted under the terms of their
waiver. Laboratories with certificates of registration may perform a full
range of laboratory tests.
30.6 CONTRACTOR shall comply with the requirements of 42 CFR Part 489, Subpart
I OBRA 1990, Patient Self- Determination Act, and ORS chapter 127, pertaining
to advance directives.
30.7 CONTRACTOR will cooperate with all processes and procedures of abuse
reporting, investigations and protective services as described in ORS 430.735
through 430.765, Abuse Reporting for Mentally Ill and OAR 309 - 040 -0200
through 309 - 040 -0290, Abuse Reporting and Protective Services in Community
Programs and Community Facilities.
30.8 CONTRACTOR shall comply with all applicable state and federal laws.
IN WITNESS WHEREOF, the parties hereto have caused this instrument to be executed in two
(2) duplicate originals by their officers, thereunto duly authorized. CONTRACTOR, BY
EXECUTION OF THIS CONTRACT, HEREBY ACKNOWLEDGES THAT
CONTRACTOR HAS READ THIS CONTRACT, UNDERSTANDS IT, AND AGREES
TO BE BOUND BY ITS TERMS AND CONDITIONS.
Accountable Behavioral Health Alliance DESCHUTES COUNTY
Seth D. Bernstein, Ph.D. Dave Kanner, County Administrator
Executive Director
Date Date
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 13 of 2 i
Attachment A -1 - Services to be Provided
1. Outpatient Services: CONTRACTOR will provide Mental Health Services to ABHA
Members consistent with applicable State OARs; the MHO Agreement; and all
applicable State and Federal laws and regulations.
2. Intensive Community-Based Treatment and Support Services (ICTS) Outpatient
Mental Health Services. CONTRACTOR will provide Mental Health Services to
ABHA Members consistent with applicable State OARs; the MHO Agreement; and all
applicable State and Federal laws and regulations.
3. CONTRACTOR may elect to provide either outpatient and /or ICTS Services through
contracted ABHA panel providers. It is the CONTRACTOR'S responsibility for the
utilization management of such Services, as described in the ABHA Utilization
Management Plan.
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 14 of 25
Attachment A -2: Subcontracted Activities And Responsibilities
1. Utilization management of outpatient and ICTS services as directed by the ABHA Utilization
Management Plan.
2. Implementation of the following ABHA policies as they pertain to the provision of outpatient
and ICTS Services:
a. Member Grievance, Appeal & Hearings Policy
b. Critical Incident Reporting Policy
c. Special Health Care Needs Policy
d. Cultural Competency Policy
e. Delivery Network Policy
f. Conflict of Interest Policy
g. ABHA Quality Management Plan
h. ABHA Utilization Management Plan
i. ABHA Practice Guidelines
3. Level 1 grievances
4. Credentialing as described in the ABHA Credentialing Policy
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 15 Af 25
Attachment A -3: Additional CONTRACTOR Requirements Listed In The MHO Agreement
All subcontracts shall meet the requirements described below. The MHO Agreement is incorporated by
reference to this contract. ABHA will provide CONTRACTOR with copies of each year's agreement
within 30 days of signature.
(1) CONTRACTOR may not subcontract any subcontracted function (see Attachnent
A -2) or responsibility to a subcontractor without the express written permissio i of
ABHA.
A. ABHA review and verification of any and all subcontracts of this Agreemer t
will precede execution of said subcontracts. If this subcontract is subcontracted,
ABHA will similarly review and verify such subcontracts before they are entez ed
into.
o Verification is for the purpose of assuring that subcontractor is qualifieI
and appropriately certified to provide services specified under this
Agreement to ABHA members.
B. Any and all subcontracts will incorporate this Agreement by reference and
include it as an attachment.
C. CONTRACTOR is responsible for all subcontracted services and functions and
may not subcontract or delegate responsibility for oversight of subcontracted
services and functions.
(2) CONTRACTOR shall continue to Provide Covered Services during periods of
CONTRACTOR insolvency or cessation of operations through the period for
which payments for services were made to CONTRACTOR.
(3)
CONTRACTOR shall have written policies and procedures for accepting,
processing and responding to all Grievances from Family Members, Local and or
regional community stakeholders, and OHP Members consistent with Exhibit N,
MHO Grievance System.
(4) CONTRACTOR will have a planned, systematic and ongoing process for
monitoring, evaluating and improving the quality and Appropriateness of Covered
Services provided to OHP Members.
(5)
CONTRACTOR will participate in QA and QI activities of ABHA, or those of
AMH if requested to do so.
(6) CONTRACTOR will cooperate with all processes and procedures of Abuse
reporting, investigations, and protective Services as described in ORS 430.735
through 430.765, Abuse Reporting for Mentally 111 and OAR 410 - 009 -0050
through 410 - 009 -0160, Abuse Reporting and Protective Services in Communit
Programs and Community Facilities.
(7)
If CONTRACTOR chooses to delegate Utilization Management activities,
CONTRACTOR shall assure that compensation to Providers is not structured s
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 16 0 25
as to provide incentives to deny, limit or discontinue Medically Appropriate
services to OHP members.
(8) CONTRACTOR will submit to ABHA all financial and other reports required in a
manner specified by the MHO Agreement.
(9) Services under this Contract may not be provided by the following persons (01
their affiliates as defined in the Federal Requisition Regulations): (a) Persons vho
are currently suspended, debarred or otherwise excluded from participating in
procurement activities under the Federal Acquisition Regulation or from
participating in non - procurement activities under regulations issues pursuant to
Executive Order No. 12549 or under guidelines implementing such order, (b)
Persons who are currently excluded from the Medicaid participation under
Section 1128 or Section 1128A of the Act. CONRACTOR will complete any; all
forms required by the MHO Agreement to verify compliance with this
requirement.
(10) CONTRACTOR shall assume the risk for providing Covered Services to its 0 HP
Members. CONTRACTOR shall provide assurances to AMH that
CONTRACTOR's provision(s) against the risk of Insolvency are adequate to
ensure that OHP Members will not be liable for CONTRACTOR's debts if
CONTRACTOR becomes insolvent.
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 17 if 25
ATTACHMENT B
DEFINITIONS
For purposes of this Agreement, the following terms shall have the meanings indicated below:
1.01 Assessment and Evaluation (A & E) Program - A service designed for children who need noil-
hospital level psychiatric assessment, evaluation and brief treatment in a secure facility progr
1.02 Behavior Rehabilitation Services (BRS) — Services available to children in the legal custody of
DHS by court order or placed with DHS through a voluntary custody or placement agreemen
signed by the child's parents or legal guardian. Programs are designed to meet Federal Medi ;aid
requirements and remediate children's psycho- social, emotional and behavioral disorders am .
encourage and reinforce children's appropriate behaviors. Services to children are individual ized
based upon a evaluation of the needs of the child. BRS programs provide an array of
rehabilitation services appropriate to the needs of the child, (i.e., individual counseling or ski 1
building, family counseling, parent training where appropriate, individual or group counselin g or
skill building). It is understood that outpatient services provided to children receiving FRS
services will be as an adjunct and not a replacement to services provided as part of the 3RS
requirements
1.03 Billable Charge: the cost of each unit of service provided, as reported by CONTRACTOR.
1.04 Case Management and Utilization Review Program — the procedures and standards established
and administered by ABHA to ensure that the Behavioral Health Services provided to Members
are Medically Necessary and appropriate.
1.05 Claim: a request for payment by a medical provider for a specific medical service.
1.06 Co- payment — are charges in addition to those charges paid by ABHA that may be directly
assessed against the Member by CONTRACTOR at the time of the provision of certain
Behavioral Health Services if co- payments are a feature of Member's mental health benefit. All
Co- payments are deducted from CONTRACTOR'S contracted fees with ABHA.
1.07 Community Mental Health Program (CMHP): The organization of all services for persons wkth
mental or emotional disorders and developmental disabilities operated by, or contractually
affiliated with, a Local Mental Health Authority, operated in a specific geographic area of th
state under an intergovernmental agreement or direct contract with DHS.
1.08 Covered Services — are Medically Necessary Behavioral Health Services provided to an eligible
Member as part of a Health Plan pursuant to this Agreement for which CONTRACTOR is
qualified to provide and accepts payment from Payor as payment in full, except for applicable
Deductibles and Co- payments.
1.09 Credentialing: The process which ensures that professionals and other providers who will deliver
services to OHP Members are licensed to practice, or otherwise qualified for their respective
positions. This is determined by comparison of practitioner qualifications with applicable
requirements for education, licensure, professional standing, experience, service availability and
accessibility, and conformance with ABHA utilization and quality management requirement ;.
1.10 Critical Incidents: Incidents which include physical injury to consumer, death, suicide atteml rt,
abuse by provider or provider's staff, serious property damage, threats to the safety of others and
other incidents of a similarly serious nature.
DESCHUITES COUNTY / ABHA IGA 2009 -2014 Page 1, of 25
1.11 Culturally Competent: The Capacity to Provide services in an effective manner that is sensiti ve
to the culture, race, ethnicity, language and other differences of an individual. Such services
may include, but are not limited to, use of bilingual and bicultural staff, provision of services in
culturally appropriate alternative settings, and use of bicultural paraprofessionals as
intermediaries with professional staff.
1.12 Deductible: The amount of money, if any, a Member must pay before a Health Plan begins
paying for Behavioral Health Services.
1.13 DHS: Department of Human Services established in ORS Chapter 409, including such divisic )ns,
programs and offices as may be established therein.
1.14 Emergency Service: Inpatient or outpatient Covered Services by a Provider that is qualified i o
provide these services and that are needed to evaluate or stabilize an Emergency Situation. SI e
definition for Twenty -four (24) Hour Urgent and Emergency Services.
1.15 Emergency Situation: A mental health condition manifesting itself by acute symptoms of
sufficient severity such that a prudent layperson, with an average knowledge of health and
medicine, could reasonably expect the absence of immediate medical attention to result in (1
serious jeopardy to the health of the OHP Member, (2) serious impairment of bodily functior, or
(3) serious dysfunction of any bodily organ or part. An "Emergency Medical Condition" is
determined based on the presenting symptoms (not the final diagnosis) as perceived by a prui lent
layperson (rather than a Health Care Professional) and includes cases in which the absence o
immediate medical attention would not in fact have had the adverse results described in the
previous sentence.
1.16 Fee - For - Service (FFS): The payment for reimbursable services retrospectively based upon
agreed rates and the amount of service provided.
1.17 Fully Capitated Health Plans (FCHPs): PHPs that contract with DHS to Provide physical health
care services under the OHP Medicaid Demonstration Project and SCHIP.
1.18 Health Plan(s): Behavioral Health Services benefit plan(s) through which ABHA is responsible
for the provision of Behavioral Health Services to Members, including, but not limited to the
Oregon Health Plan.
1.19 Intensive Community -Based Treatment and Support Services ( "ICTS "): A specialized set of in-
home and community -based supports and mental health treatment services that are delivered in
the most normative, least restrictive setting. Intensive community -based treatment and support
services include, but are not limited to: crisis prevention and intervention; care coordination
case management; individual, group, and family therapy; psychiatric services; skills training
support; respite care; and team - driven service coordination planning.
1.20 Intensive Treatment Services ( "ITS "): The range of service components in the system of can;
inclusive of treatment foster care, psychiatric day treatment, residential psychiatric treatment,
sub -acute care or other services that provides active psychiatric treatment for children with
severe emotional disorders and their families.
1.21 Medically Necessary Services: Services and supplies which are required for Prevention
(including preventing a relapse), Diagnosis or Treatment of mental disorders and which are
appropriate and consistent with the Diagnosis; consistent with treating the symptoms of a ml , ntal
illness or treatment of a mental disorder; appropriate with regard to standards of good practi, , e
and generally recognized by the relevant scientific community as effective; not solely for thf,
convenience of the OHP Member or provider of the service or supply; and the most cost
effective of the alternative levels of Covered Services or supplies which can be safely and
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 1 of 25
effectively provided to the OHP Member in CONTRACTOR's judgment. An intervention
recommended by the treating practitioner that is:
a. A behavioral health intervention for the purpose of treating a behavioral health condit on;
b. Delivered at an appropriate level of service, considering potential benefits and harm ti i
the Member;
c. Known to be effective in treating the behavioral health condition.
1.22 Member — is an individual who is enrolled in the Oregon Health Plan and assigned to ABHA or
is otherwise covered under an intergovernmental agreement between ABHA and the State of
Oregon and who meets all the eligibility requirements for membership in such plan.
1.23 Member Handbook: A booklet that is mailed to all ABHA Members when they first become
enrolled in the Oregon Health Plan. The handbook describes member rights and responsibilii ies
as well as how Members can access services, as well as a number of responsibilities that relate to
work performed by CONTRACTOR.
1.24 Mental Disorder: A mental or nervous condition diagnosed by a Practitioner according to the
criteria in the most current version of the Diagnostic and Statistical Manual of Mental Disordrs
(DSM).
1.25 Mental Health Practitioner: The supervising psychiatrist, psychologist or other allied behavic ral
health professional that is qualified and duly licensed or certified under the laws of the State )f
Oregon.
1.26 Notice of Action: A written document which includes the following elements: (a) a statemen of
the Action, the effective date of such Action, and the date the Notice of Action is mailed; (b) the
reasons for the Action and the specific regulations that support the Action; (c) an explanation of
the right to file a Complaint with CONTRACTOR and to request an Administrative Hearing with
DHS, and the consequences of choices made; (d) a statement referring the OHP Member to n
enclosed informational notice of Complaint process form; (e) a statement referring the OHP
Member to an enclosed informational notice of Hearing rights form; and (f) the name and
telephone number of a person to contact for additional information.
1.27 Outpatient Mental Health Services: Behavioral Health Services provided for the treatment of
Mental Disorders in an outpatient setting by a mental health practitioner.
1.28 Oregon Health Plan (OHP): The OHP is the managed care plan for providing Medicaid services
to covered members in Oregon.
1.29 Panel Provider: a State licensed or certified practitioner under contract with ABHA who
provides Services to ABHA members as authorized by CONTRACTOR.
1.30 Payment Amounts: Monies payable to CONTRACTOR pursuant to this Agreement as
compensation for Behavioral Health Services provided to Members.
1.31 Proctor Care: Behavioral health care programs providing 24 -hour, seven days per week acti\ e
mental health treatment in certified homes.
1.32 Psychiatric Day Treatment: services are comprehensive, interdisciplinary, non - residential
community based programs consisting of psychiatric treatment, family treatment and therapy utic
activities integrated with an accredited education program. Services are clinically and
developmentally appropriate and are provided in the medically appropriate amount, intensiti and
duration for each admitted child specific to the child's diagnosis, level of functioning and thi
acuity and severity of the child's psychiatric symptoms.
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 21 i of 25
1.33 Psychiatric Residential Treatment Services (PRTS): A residential program that is operated to
provide supervision, care and treatment on a 24 -hour basis for children in a psychiatric treatment
setting which conforms to established state - approved standards, consistent with ORS 443.40(
through ORS 443.455.
1.34 Quality Assurance: A full cycle of activities for monitoring and assuring Quality of Care..
1.35 Quality Assessment/Performance Improvement (QA /PI) Plan: A program that includes the basic
elements of a QA /PI Plan as described in 42 CRF 438.240.
1.36 Reasonable Accommodation: Consistent with the Americans with Disabilities Act of 1990 ar d
Section 504 of the Rehabilitation Act of 1973, a modification to policies, practices, or proced .fires
when the modification is necessary to avoid discrimination on the basis of Disability unless to fie
service provider can demonstrate that making the modification would fundamentally alter the .
nature of the service, program or activity. Reasonable Accommodations may include, but an not
limited to, activities such as the following: (1) reading, or providing a tape of, material
otherwise provided in written format to a person with a visual impairment; (2) providing a
service in a more accessible location for a person with a mobility and other impairment; (3)
providing assistance to a person with a Disability in completing applications and other
paperwork necessary to receipt of services; and (4) modifying a waiting area layout to
accommodate a person in a wheelchair.
1.37 Respite Care: Planned and emergency interventions designed to provide temporary relief for
caregiver or client in order to maintain a stable and safe living environment. Respite care can be
provided in or out of the home and includes supervision and behavioral support for the child.
Services must be reasonably expected to improve or maintain the condition and functional le vel
and prevent relapse or hospitalization. Agency supervision shall include training, supervision in
adhering to the client treatment plan, and emergency back -up support.
1.38 Service: The care, treatment, service Coordination or other assistance provided to an ABHA
Member
1.39 Services Coordination: Services provided to OHP Members who require access to and /or rec five
services from one or more Allied Agencies or program components according to the Treatmc nt
Plan. Services provided may include establishing pre- commitment service linkages; advocat ing
for treatment needs; and providing assistance in obtaining entitlements based on mental or
emotional Disability.
1.40 Sub -Acute Residential Services: Mental health treatment under the clinical direction of a
psychiatrist as an alternative to hospitalization certified for children who are not in the most
acute phase of a mental condition but who require a level of care higher than that provided ill a
residential psychiatric treatment setting.
1.41 Sub - capitated Claim: a claim, submitted electronically by CONTRACTOR to ABHA's Thi7 d
Party Administrator, which does not result in payment to CONTRACTOR, but is rather a record
of the service that was provided.
1.42 Subcontracted Activities: managed care functions required under the MHO Agreement whic I are
administrative in nature (e.g., credentialing and utilization management) and would ordinari y be
performed by the MHO, but are performed instead by CONTRACOR under the terms of thi:
Agreement.
1.43 Third Party Resources and Personal Injury Lien: "Third Party Resources" mean any payme Its,
benefits, or other resources available from a Third Party, including but not limited to:
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 2 of 25
a. Private health insurance or group health plan;
b. Employment - related health insurance;
c. Medical support from absent parents;
d. Workers' compensation;
e. Medicare;
f. Automobile liability insurance; and
g. Other federal programs such as Veteran's Administration, Armed Forces Retirees and
Dependent Act (CHAMPVA), Armed Forces Active Duty and Dependents Military
Medical Benefits Act (CHAMPUS), and Medicare Parts A and B, unless excluded by
statute as for example:
h. Services provided to OHP Members pursuant to 42 CFR 136.61 Indian Health Servics:
(IHS) is the payor of last resort and is not considered a Third Party Resource; or
i. Services provided to OHP Members at a tribal facility operated under a "638" agreement
pursuant to the Memorandum of Agreement between IHS and CMS is a payor of last
resort and is not considered a Third Party Resource.
j. Claims, judgments, settlements or compromises in relation to personal injuries where the
Covered Services paid by CONTRACTOR constitute assistance, as these terms are
defined in ORS 416.510
1.44 Treatment Foster Care: Mental health treatment for children residing in certified homes when
the home parents are employed or contracted by the supervising agency to provide in -home
psychosocial skills development for each child.
1.45 Usual and Customary Charges: A required field in the encounter Minimum Data Set which
reflects the provider's charge per unit of service established in accordance with OAR 410 -12)-
0000 or other applicable state and federal laws, rules and regulations, not in excess of the
provider's usual and customary charge to the general public.
1.46 Utilization Management - The process of reviewing and authorizing medically necessary
services.
1.47 Valid Claim: An invoice received by the CONTRACTOR for payment of Covered Services
rendered to an OHP Member which can be processed without obtaining additional information
from the provider of the service or from a third party; and has been received within the time
limitations prescribed in Oregon Administrative Rule 410 - 141 -0420; Billing and Payment ut [der
the Oregon Health Plan and is synonymous with the federal definition of a "clean claim" as
defined in 42 CFR 447.45(b).
* * * End of Attachment B * * *
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 2? of 25
ATTACHMENT C
ACCOUNTABLE BEHAVIORAL HEALTH ALLIANCE
ELECTRONIC TRADING PARTNER RELATIONSHIP AGREEMENT
This is an agreement by and between DESCHUTES COUNTY, a political subdivision of the State of
Oregon, hereafter called CONTRACTOR, and ACCOUNTABLE BEHAVIORAL HEALTH ALLIANCE, at,
ORS Chapter 190 Intergovernmental Organization, hereinafter called ABHA.
CONTRACTOR may have access to and /or receive from ABHA certain Information that can be used or disch sed
only in accordance with this agreement and the federal HHS Privacy Regulations.
To the extent required by 42 U.S.C. 1171 et seq. enacted by the Health Insurance Portability and Accountabili :y
Act of 1996 and regulations promulgated thereunder, CONTRACTOR assures ABHA that CONTRACTOR v ill
appropriately safeguard protected health information made available to or obtained by CONTRACTOR.
CONTRACTOR further agrees to comply with applicable laws relating to protected health information and AN ith
respect to any task or other activity CONTRACTOR performs on behalf of ABHA, to the extent ABHA woul I be
required to comply with such requirements.
For purposes of this agreement, the following terms shall apply:
A. CONTRACTOR shall be considered a BUSINESS ASSOCIATE;
a. A Business Associate is defined as a person or entity who, on behalf of ABHA, either performs or
assists in the performance of covered functions, or provides one or more of the following typ's of
services to ABHA: legal, actuarial, accounting, consulting, HIPAA - defined data aggregation .
management, administration, accreditation and financial services, provided, any such partial .)r
full performance of covered functions or provision of specified services involves the disclose re or
other use of protected health information.
B. ABHA shall be considered a COVERED ENTITY;
C. Federal HHS Privacy Regulations shall mean the Code of Federal Regulations (C.F.R.) at Title 45,
Sections 160 and 164;
D. Individual shall mean the person who is the subject of the Information, and has the same meanin; as
the term `individual' is defined by 45 C.F.R. 164.501; and
E. Secretary shall mean the Secretary of the U.S. Department of Health and Human Services (HHS ? and
any other officer or employee of HHS to whom the authority involved has been delegated;
F. Information shall mean any health information provided and /or made available by ABHA to
CONTRACTOR, and has the same meaning as the term `health information' as defined by 45 C F.R.
160.102.
CONTRACTOR agrees it shall:
1. Not use or further disclose such information other than as permitted or required by this agreement.
CONTRACTOR shall not, except as necessary data collection relating to ABHA or for the proper managern;nt,
administration and performance of its duties under this agreement, use, reproduce, disclose, or provide to thi -d
parties, any confidential document or information relating to the ABHA or clients of ABHA without the pric r
written consent or authorization of the ABHA or of the client. If CONTRACTOR uses such information foi the
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 3 of 25
purposes set forth above, it will only do so if the disclosure is required by law or CONTRACTOR obtains written
assurances from the person to whom the information is disclosed that it will be held confidentially and used or
further disclosed only as required by law or for the purpose for which CONTRACTOR disclosed it to the person.
CONTRACTOR shall ensure that its personnel, employees, affiliates and agents maintain the confidentiality of
patient health information and business information of ABHA.
2. Not use or further disclose the information other than as permitted or required by this agreement or as
required by law;
3. Use appropriate safeguards to prevent use or disclosure of such information other than as provided for by
this agreement;
4. Report to ABHA any use or disclosure of such information not provided for by this agreement of whis ,h
CONTRACTOR becomes aware;
5. Ensure that any subcontractors or agents to whom CONTRACTOR provides protected health information
received from ABHA agree to the same restrictions and conditions that apply to CONTRACTOR with respect to
such information;
6. Will give individuals the right of access, amendment and accounting regarding their protected health
information in accordance with applicable law;
7. Maintain standard records, pursuant to this agreement, and provide such records and other necessary
information to the ABHA as may be requested in writing and as permitted by law. CONTRACTOR agrees that
all records kept in connection with this agreement are subject to review and audit by the ABHA upon reasonable
notice of a minimum of 14 work days from the date of written request by the ABHA.
8. Make CONTRACTOR'S internal practices, books, and records relating to the use and disclosure of
protected health information received from ABHA available to the ABHA and the Secretary of the United States
Health & Human Services for purposes of determining ABHA'S compliance with applicable law (in all events,
CONTRACTOR shall immediately notify ABHA upon receipt of any such request, and shall provide ABHA with
copies of any such materials);
9. Upon termination of this agreement, CONTRACTOR promptly return all protected health information
received from ABHA. if the return of protected health information is not feasible, CONTRACTOR shall con inue
the protections required under this contract in a manner consistent with the requirements of this Attachment nd
the HIPAA privacy standards.
10. Shall not change any definition, data condition or use of a data element or segment in a standard, add any
data elements or segment to the maximum defined data set, use any code or data elements that are either mar,:ed
"not used" in the standard's implementation specification or are not in the implementation specification, or
change the meaning or intent of the implementation specification.
1 1. Shall incorporate any amendments or corrections to protected health information when notified purse [ant
to applicable law.
DESCHUTES COUNTY / ABHA IGA 2009 -2014 Page 4 of 25
ABHA and CONTRACTOR agree to protect the integrity and confidentiality of any protected health informat on
exchanged between them and other appropriate business associates, if any.
CONTRACTOR:
DESCHUTES COUNTY
2577 NE Courtney Drive
Bend, OR 97701
(541) 322 -7500
ABHA:
Accountable Behavioral Health Alliance
3 l 0 NW 5th Street, Suite 206
Corvallis, OR. 97330
(541) 753-8997
IN WITNESS WHEREOF, the parties hereto have caused this instrument to be executed in two (2) duplicate originals, e ther
as individuals, or by their officers, thereunto duly authorized.
DATED this First day of August 2009
ACCOUNTABLE BEHAVIORAL
HEALTH ALLIANCE
Seth D. Bernstein, Ph.D., Executive Director
Date
CONTRACTOR
Authorized Contract Representative
Date
DESCHUTES COUNTY / ABHA IGA 2009 -2014
Page : 5 of 25
Certificate of Self- Insurance
This is to certify that Deschutes County, Oregon is a self- insured entity pursuant
to ORS 30.282 and has established a self- insured fund against liability and
property damage arising out of any tort claims against its programs, officers,
agents, employees and volunteers acting within the scope of their employment.
This coverage is applicable under any Deschutes County agreement.
Please refer inquiries to:
Deschutes County Risk Management
Erik Kropp, Risk Manager (541) 388 -6584
Judy Sumners, Claims Coordinator (541) 385 -1749
Ken Harms, Loss Prevention Specialist (541) 617 -4747
1300 NW Wall St., Ste. 200, Bend, OR 97701
Effective Date 12/17/08, no expiration