HomeMy WebLinkAboutResolutions - 2004.11.18 - 27618MISCELLANEOUS RESOLUTION 104319) November 18, 2004
BY: General Government Committee, William R. Patterson, Chairperson
IN RE: DEPARTMENT OF HUMAN SERVICES/HEALTH DIVISION - 2004/2005 SUBSTANCE ABUSE
GRANT ACCEPTANCE
To the Oakland County Board of Commissioners
Chairperson, Ladies and Gentlemen:
WHEREAS the Health Division has been awarded by the Michigan Department
of Community Health (MDCH) $4,654,916 in Substance Abuse Grant Funds for the
period of October 1, 2004 through September 30, 2005; and
WHEREAS the 2004/2005 grant award includes $4,654,916 in grant revenue and
expenditures for this program, a decrease of $47,698 (1%) from the previous year;
and
WHEREAS these funds are used to subcontract with agencies to prevent and
reduce the incidence of drug and alcohol abuse and dependency; and
WHEREAS these contracts were awarded through the County's competitive
bidding process; and
WHEREAS acceptance of this grant does not obligate the County to any
future commitment; and
WHEREAS the grant agreement has been submitted through the County
Executive's Contract Review Process.
NOW THEREFORE BE IT RESOLVED that the Oakland CountY Board of
Commissioners accepts the 2004/2005 Substance Abuse Grant from the Michigan
Department of Community Health in the amount of $4,654,916.
BE IT FURTHER RESOLVED that the Chairperson of the Board of Commissioners
is authorized to execute the grant agreement and to approve minor changes and
grant extensions, not to exceed fifteen (15) percent variance from the original
award.
BE IT FURTHER RESOLVED that the future level of service, including
personnel, be contingent upon the level of funding for this program.
BE IT FURTHER RESOLVED that the Oakland County Board of Commissioners
authorizes its Chairperson to execute this Agreement subject to the following
additional condition: That the County's approval for entering into this Agreement
is specifically conditioned and premised upon the acceptance, approval and
execution of the Agreement containing Addendum A, by the Michigan Department of
Community Health, and that the failure of the Michigan Department of Community
Health to execute the Agreement as specified shall, without any further act of
the Oakland County Board of Commissioners, automatically negate and void the
County's approval and/or acceptance of this agreement as provided for in this
resolution.
Chairperson, on behalf of the General Government Committee, I move the
adoption of the foregoing resolution.
GENERAL GOVERNMENT COMMITTEE A
k: ifr/L4' 111 11)caa7-4-Wi General Government Committee Vote:
Motion carried on a roll call vote with Hatchett absent.
Tom Fockler
From:
Sent:
To:
Cc:
Subject:
Greg Givens [givensg@co.oakland.mi.us ]
Friday, October 29, 2004 3:16 PM
Doyle, Larry; Fockler, Tom
Pearson, Linda; Smith, Laverne; Frederick, Candace; Worthington, Pam; Pardee, Mary;
Hanger, Helen
CONTRACT REVIEW — Health Division / Substance Abuse
CONTRACT REVIEW - Health Division
GRANT NAME: FY 04-05 MDCH - Local Health Department Substance Abuse Agreement
FUNDING AGENCY: Michigan Department of Community Health DEPARTMENT CONTACT
PERSON: Tom Fockler / 2-2151
STATUS: Acceptance
DATE: October 29,2004
Pursuant to Misc. Resolution #01320, please be advised the captioned grant materials
have completed internal contract review. Below are the comments returned by review
departments.
The captioned grant materials and grant acceptance package (which should include the
Board of Commissioners' Liaison Committee Resolution, the grant agreement/contract,
Finance Committee Fiscal Note, and this email containing grant review comments) may
be requested to be placed on the appropriate Board of Commissioners' committee(s) for
grant acceptance by Board resolution.
Department of Management and Budget:
Approved.- Laurie Van Pelt (10/29/2004)
Department of Human Resources:
Approved. - Ed Poisson (10/26/2004)
Risk Management and Safety:
Approved by Risk Management - Julie Secontine (10/27/2004)
Corporation Counsel:
I have review the Substance Abuse Grant Agreement, and with the inclusion of the
modified Addendum A as provided by Tom Fackler, approve it for acceptance and
signature. - John Ross (10/29/2004)
2
Contract #:
Grant Agreement Between
Michigan Department of Community Health
hereinafter referred to as the "Department"
and
Oakland County Health Division
250 Elizabeth Lake Road, Suite 1550
Pontiac, Michigan 48341
Federal I.D.#: 38-6004876
hereinafter referred to as the "Contractor"
for
Substance Abuse Services
Part I
1. Period of Agreement: This agreement shall commence on October 1,2004 and
continue through September 30, 2005. This agreement is in full force and effect
for the period specified.
2. Program Budget and Agreement Amount
A. Agreement Amount
The total amount of this agreement is $ The
Department under the terms of this agreement will provide funding not to
exceed $4,654,916. The federal funding provided by the Department is
approximately 68%; for SAPT Block Grant funds, the Catalog of Federal
Domestic Assistance (CFDA) number is 93.959 and the CFDA Title is
Block Grant for Prevention and Treatment of Substance Abuse; the
federal agency name is Department of Health and Human Services; the
federal grant award number is 00 B1 MI SAPT 05 and federal program title
is SAPT Block Grant.
B. Equipment Purchases and Title
Any contractor equipment purchases supported in whole or in part through
this agreement must be listed in the supporting Equipment Inventory
Schedule which is located in Attachment B to this Agreement. Equipment
means tangible, non-expendable, personal property having useful life of
more than one (1) year and an acquisition cost of $5,000 or more per unit.
ncH 05FY2005 4104 (W)
Item 2.B is
not
applicable
Page 1 of 15
Title to items having a unit acquisition cost of less than $5,000 shall vest
with the Contractor upon acquisition. The Department reserves the right
to retain or transfer the title to all items of equipment having a unit
acquisition cost of $5,000 or more, to the extent that the Department's
proportionate interest in such equipment supports such retention or
transfer of title.
C. Deviation Allowance
A deviation allowance modifying an established budget category by
$10,000 or 15%, whichever is greater, is permissible without prior written
approval of the Department. Any modification or deviations in excess of
this provision, including any adjustment to the total amount of this
agreement, must be made in writing and executed by all parties to this
agreement before the modifications can be implemented. This deviation
allowance does not authorize new categories, subcontracts, equipment
items or positions not shown in the attached Program Budget Summary
and supporting detail schedules.
3. Purpose: The focus of the program is to provide for the administration and
coordination of substance abuse services within the designated coordinating
agency region, consisting of Oakland County.
4. Statement of Work: The Contractor agrees to undertake, perform and complete
the services described in Attachment A, which is part of this agreement through
reference.
Item 2.0
is not
applicable
5. Financial Requirements: The reimbursement process shall be followed as
described in Part II of this agreement and Attachments B, D and E, which are
part of this agreement through reference.
6. Performance/Progress Report Requirements: The progress reporting
methods, as applicable, shall be followed as described in Attachment C, which is
part of this agreement through reference.
7. General Provisions: The Contractor agrees to comply with the General
Provisions outlined in Part II, which is part of this agreement through reference.
Attachment F contains additional requirements and is also incorporated into this
agreement through reference.
8. Administration of the Agreement:
The person acting for the Department in administering this agreement
(hereinafter referred to as the Contract Manager) is:
Mark Steinberg: Cass Bldg: Manager. S/A Abuse Contract Management; 517/335-018Q
SteinbergM@michigan.gov
Name, Location/Building Title Telephone No. Email Address
DCH-0665FY2005 4104 (W)
Page 2 of 15
Name (Please print)
9. Contractor's Financial Contact for the Agreement:
The person acting for the Contractor on the financial reporting for this agreement
is:
Sandra Kosik Coordinator
Name Title
Kosiks(a.co.oakland.mi.us 248/858-0001
E-Mail Address Telephone No.
10. Special Conditions:
A. This agreement is valid upon approval by the State Administrative Board
as appropriate and approval and execution by the Department.
B. This agreement is conditionally approved subject to and contingent upon
the availability of funds.
C. The Department will not assume any responsibility or liability for costs
incurred by the Contractor prior to the signing of this agreement.
11. Special Certification:
The individual or officer signing this agreement certifies by his or her signature
that he or she is authorized to sign this agreement on behalf of the responsible
governing board, official or Contractor.
12. Signature Section:
For the CONTRACTOR
Signature
For the MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
Michael Ezzo, Ed. D., Chief Deputy Director
DCH-0665FY2005 4/04 (W)
Date
Date
Page 3 of 15
Part II
General Provisions
Responsibilities - Contractor
The Contractor in accordance with the general purposes and objectives of this
agreement will:
A. Publication Rights
1_ Where activities supported by this agreement produce books, films,
or other such copyrightable materials issued by the Contractor, the
Contractor may copyright such but shall acknowledge that the
Department reserves a royalty-free, non-exclusive and irrevocable
license to reproduce, publish and use such materials and to
authorize others to reproduce and use such materials. This cannot
include service recipient information or personal identification data.
2. Any copyrighted materials or modifications bearing
acknowledgment of the Department's name must be approved by
the Department prior to reproduction and use of such materials.
3. The Contractor shall give recognition to the Department in any and
all publications papers and presentations arising from the program
and service contract herein; the Department will do likewise.
B. Fees
Make reasonable efforts to collect 1 st and 3rd party fees, where applicable,
and report these as outlined by the Department's fiscal procedures. See '-
Attachment A, Item 5, and Attachment B. The contractor must exclude
from reimbumabla expenditures any underrecoveries of otherwise „
available fees resulting from failure to bill for eligible services.
C. Program Operation
Provide the necessary administrative, professional, and technical staff for
operation of the program.
D. Reporting
Utilize all report forms and reporting formats required by the Department
at the effective dale of this agreement, and provide the Department with
timely review and commentary on any new report forms and reporting
formats proposed for issuance thereafter.
E. Record Maintenance/Retention
Maintain adequate program and fiscal records and files, including source
documentation to support program activities and all expenditures made
under the terms of this agreement, as required.
Assure that all terms of the agreement will be appropriately adhered to
and that records and detailed documentation for the project or program
DC1-1-0665PY2005 4104 (W)
Page 4 of 15
identified in this agreement will be maintained for a period of not less than
three (3) years from the date of termination, the date of submission of the
final expenditure report or until litigation and audit findings have been
resolved.
F. Authorized Access
Permit upon reasonable notification and at reasonable times, access by
authorized representatives of the Department, Federal Grantor Agency,
Comptroller General of the United States and State Auditor General, or
any of their duly authorized representatives, to records, files and
documentation related to this agreement, to the extent authorized by
applicable state or federal law, rule or regulation.
G. Audits
1. Single Audit
Provide, consistent with regulations set forth in the Single Audit Act
Amendments of 1996, P.L. 104-156, and Section .320 of Office of
Management and Budget (OMB) Circular A-133, "Audits of States,
Local Governments, and Non-Profit Organizations," a copy of the
annual Single Audit reporting package of the Contractor to the
Department. The reporting package must include the supple-
mental schedules as enumerated in the current version of the
MDCH Audit Guidelines (hereinafter referred to as "supplemental
schedules").
The federal OMB Circular A-133 requires either a Single Audit or
program-specific audit (when a contractor is administering only one
federal program) of agencies that expend $500,000 or more in
federal awards during the Contractor's fiscal year.
Contractors who have a Single Audit conducted as a result of
$500,000 or more in expenditures of Federal funds must submit the
Single Audi reporting package and management letter, if issued, to
the Department even if Federal funding received from the
Department results in less than $500,000 in expenditures.
The Contractor must assure that each of its subcontractors
comply with the above Single Audit requirements, as applicable, ,
and provide for other subcontractor monitoring procedures, as,
deemed necessary. The Contractor must also assure that the
Schedule of Expenditures of Federal Awards includes expenditures
for all federally funded grants.
2. Financial Statement Audit
Contractors exempt from the Single Audit requirements that receive
$500,000 or more in total funding from the Department in State
and Federal grant funding must submit a copy of the Financial
Statement Audit prepared in accordance with generally accepted
auditing standards (GAAS), and management letter, if one is issued
and the supplemental schedules. Contractors exempt from the
Single Audit requirements that receive less than $500,000 of total
Department grant funding must submit the supplemental schedules
and a copy of the Financial Statement Audit prepared in
accordance with GAAS if the audit includes disclosures that may
negatively impact MDCH-funded programs, including, but not
limited to fraud, going concern uncertainties, financial statement
misstatements, and violations of contract and grant provisions.
3. Other Audits
The Department or federal agencies may also conduct or arrange
for "agreed upon procedures" or additional audits to meet their
needs.
4. Notification
When a Contractor is exempt from both the Single Audit
requirements and the Financial Statement Audit requirements
because funding is below the thresholds described above and there
are no disclosures that may negatively impact MDCH-funded
programs, the Contractor must submit an Audit Status Notification
Letter that certifies these exemptions. Attachment E contains a
sample Audit Status Notification Letter.
5. Due Date
The Single Audit reporting package and management letter, if one
is issued, Financial Statement Audit and management letter, if one
is issued, or Audit Status Notification Letter shall be submitted to
the Department within nine months after the end of the Contractor's
fiscal year.
6. Penalty
a. Delinquent Single Audit or Financial Statement Audit
If the Contractor does not submit the required Single Audit
reporting package and management letter, or the Financial
Statement Audit and management letter within nine months
after the end of the Contractor's fiscal year, the Department
may withhold from the current funding an amount equal to
five percent of the audit year's grant funding (not to exceed
$100,000) until the required filing is received by the
Department. The Department may retain the amount
withheld if the contractor is more than 120 days delinquent in
meeting the filing requirements.
b. Delinquent Audit Status Notification Letter
Failure to submit the Audit Status Notification Letter, when
required, may result in withholding from the current funding
an amount equal to one percent of the audit year's grant
funding until the Audit Status Notification Letter is received.
Where to Send
A copy of the Single Audit reporting package and management
letter, if one is issued, Financial Statement Audit and management
letter, if one is issued, or the Audit Status Notification Letter must
be forwarded to:
Michigan Department of Community Health
Office of Audit
Quality Assurance and Review Section
P.O. Box 30479
Lansing, Michigan 48909-7979
Or
Capital Commons Center
400 S. Pine Street
Lansing, Michigan 48933
8. Management Decision
The Department shall issue a management decision on findings
and questioned costs contained in the Contractor's Single Audit
within six months after the receipt of a complete and final audit
report. The management decision shall include whether or not the
audit finding is sustained; the reasons for the decision; and the
expected Contractor action to repay disallowed costs, make
financial adjustments, or take other action. Prior to issuing the
management decision, the Department may request additional
information or documentation from the Contractor, including a
request for auditor verification of documentation, as a way of
mitigating disallowed costs.
H. Notification of Modifications
Provide timely notification to the Department, in writing, of any action by its
governing board or any other funding source that would require or result in
significant modification in the provision of services, funding or compliance
with operational procedures.
CI)-(Vt Software Compliance —A
The Contractor must ensure software compliance and compatibility with
the Department's data systems for services provided under this
agreement including but not limited to: stored data, databases, and
interfaces for the production of work products and reports. All required
data under this agreement shall be provided in an accurate and timely
manner with out interruption, failure or errors due to the inaccuracy of the
Contractor's business operations for processing date/time data.
J. Human Subjects
The Contractor agrees to submit all research involving human subjects,
which is conducted in programs sponsored by the Department, or in
programs which receive funding from or through the State of Michigan, to
the Department's Human Subjects Committee for approval prior to the
initiation of the research.
Responsibilities - Department
The Department in accordance with the general purposes and objectives of this
agreement will:
A. Reimbursement
Provide reimbursement in accordance with the terms and conditions of
this agreement based upon appropriate reports, records, and
documentation maintained by the Contractor.
B. Report Forms
Provide any report forms and reporting formats required by the
Department at the effective date of this agreement, and provide to the
Contractor any new report forms and reporting formats proposed for
issuance thereafter at least ninety (90) days prior to their required usage
in order to afford the Contractor an opportunity to review and offer
comment.
Ill. Assurances
The following assurances are hereby given to the Department:
A. Compliance with Applicable Laws
The Contractor will comply with applicable federal and state laws,
guidelines, rules and regulations in carrying out the terms of this
agreement. The Contractor will also comply with all applicable general
administrative requirements such as OMB Circulars covering cost
principles, grant/agreement principles, and audits in carrying out the terms
of this Agreement. For purposes of this Agreement, OMB Circular A-87 is
applicable to Contractors that are local government entities, and OMB
Circular A-122 is applicable to Contractors that are non-profit entities.
B. Anti-Lobbying Act
The Contractor will comply with the Anti-Lobbying Act, 31 USC 1352 as
revised by the Lobbying Disclosure Act of 1995, 2 USC 1601 et seq, and
Section 503 of the Departments of Labor, Health and Human Services and
Education, and Related Agencies Appropriations Act (Public Law 104-
208). Further, the Contractor shall require that the language of this
assurance be included in the award documents of all subawards at all tiers
(including subcontracts, subgrants, and contracts under grants, loans and
cooperative agreements) and that all subrecipients shall certify and
disclose accordingly.
C. Non-Discrimination
1. In the performance of any contract or purchase order resulting
herefrom, the Contractor agrees not to discriminate against any
employee or applicant for employment or service delivery and
access, with respect to their hire, tenure, terms, conditions or
privileges of employment, programs and services provided or any
matter directly or indirectly related to employment, because of race,
color, religion, national origin, ancestry, age, sex, height, weight,
marital status, physical or mental disability unrelated to the
individual's ability to perform the duties of the particular job or
position or to receive services. The Contractor further agrees that
every subcontract entered into for the performance of any contract
or purchase order resulting herefrom will contain a provision
requiring non-discrimination in employment, service delivery and
access, as herein specified binding upon each subcontractor. This
covenant is required pursuant to the Elliot-Larsen Civil Rights Act,
1976 PA 453, as amended, MCL 37.2201 et seq., and the Persons
with Disabilities Civil Rights Act, 1976 PA 220, as amended, MCL
37.1101 et seq., and any breach thereof may be regarded as a
material breach of the contract or purchase order.
2. Additionally, assurance is given to the Department that proactive
efforts will be made to identify and encourage the participation of
minority owned and women owned businesses, and businesses
owned by handicapped persons in contract solicitations. The
Contractor shall incorporate language in all contracts awarded: (1)
prohibiting discrimination against minority owned and women
owned businesses and businesses owned by handicapped persons
in subcontracting; and (2) making discrimination a material breach
of contract.
D. Debarment and Suspension
Assurance is hereby given to the Department that the Contractor will
comply with Federal Regulation, 45 CFR Part 76 and certifies to the best
of its knowledge and belief that it, including its employees and
subcontractors:
1. Are not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from covered
transactions by any federal department or contractor;
2. Have not within a three-year period preceding this agreement been
convicted of or had a civil judgment rendered against them for
commission of fraud or a criminal offense in connection with
obtaining, attempting to obtain, or performing a public (federal,
state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of
records, making false statements, or receiving stolen property;
3. Are not presently indicted or otherwise criminally or civilly charged
by a government entity (federal, state or local) with commission of
any of the offenses enumerated in section 2, and;
4. Have not within a three-year period preceding this agreement had
one or more public transactions (federal, state or local) terminated
for cause or default.
E. Federal Requirement: Pro-Children Act
Assurance is hereby given to the Department that the Contractor
will comply with Public Law 103-227, also known as the Pro-
Children Act of 1994, 20 USC 6081 et seq, which requires that
smoking not be permitted in any portion of any indoor facility owned
or leased or contracted by and used routinely or regularly for the
provision of health, day care, early childhood development
services, education or library services to children under the age of
18, if the services are funded by federal programs either directly or
through state or local governments, by federal grant, contract, loan
or loan guarantee. The law also applies to children's services that
are provided in indoor facilities that are constructed, operated, or
maintained with such federal funds. The law does not apply to
children's services provided in private residences; portions of
facilities used for inpatient drug or alcohol treatment; service
providers whose sole source of applicable federal funds is
Medicare or Medicaid; or facilities where Women, Infants, and
Children (WIC) coupons are redeemed. Failure to comply with the
provisions of the law may result in the imposition of a civil monetary
penalty of up to $1,000 for each violation and/or the imposition of
an administrative compliance order on the responsible entity. The
-
Contractor also assures that this language will be included- in any
subawards which contain provisions for children's services.
2. The Contractor also assures, in addition to compliance with Public
Law 103-227, any service or activity funded in whole or in part
through this agreement will be delivered in a smoke-free facility or
environment. Smoking shall not be permitted anywhere in the
facility, or those parts of the facility under the control of the
Contractor. If activities or services are delivered in facilities or
areas that are not under the control of the Contractor (e.g., a mall,
restaurant or private work site), the activities or services shall be
smoke-free.
F. Hatch Political Activity Act and Intergovernmental Personnel Act
The Contractor will comply with the Hatch Political Activity Act, 5 USC 1501-
1508, and the Intergovernmental Personnel Act of 1970, as amended by
Title VI of the Civil Service Reform Act, Public Law 95-454, 42 USC 4728.
Federal funds cannot be used for partisan political purposes of any kind by
any person or organization involved in the administration of federally-
assisted programs.
n••,,a n I C
G. Subcontracts
Assure for any subcontracted service, activity or product:
1. That a written subcontract is executed by all affected parties prior to
the initiation of any new subcontract activity. Exceptions to this
policy may be granted by the Department upon written request
within 30 days of execution of the agreement.
2. That any executed subcontract to this agreement shall require the
subcontractor to comply with all applicable terms and conditions of
this agreement. In the event of a conflict between this agreement
and the provisions of the subcontract, the provisions of this
agreement shall prevail.
A conflict between this agreement and a subcontract, however,
shall not be deemed to exist where the subcontract:
a. Contains additional non-conflicting provisions not set forth in
this agreement;
b. Restates provisions of this agreement to afford the
Contractor the same or substantially the same rights and
privileges as the Department; or
c. Requires the subcontractor to perform duties and/or services
in less time than that afforded the Contractor in this
agreement.
3. That the subcontract does not affect the Contractor's accountability
to the Department for the subcontracted activity.
4. That any billing or request for reimbursement for subcontract costs
is S u pp o rted by a valid subcontract and adequate source
documentation on costs and services.
5. That the Contractor will submit a copy of the executed subcontract
if requested by the Department.
H. Procurement
Assure that all purchase transactions, whether negotiated or advertised,
shall be conducted openly and competitively in accordance with the
principles and requirements of OMB Circular A-102 (as revised),
implemented through applicable portions of the associated "Common
Rule" as promulgated by responsible federal contractor(s), or OMB
Circular A-110, as applicable, and that records sufficient to document the
significant history of all purchases are maintained for a minimum of three
years after the end of the agreement period,
Health Insurance Portability and Accountability Act
To the extent that this act is pertinent to the services that the Contractor
provides to the Department under this agreement, the Contractor assures
that it is in compliance with the Health Insurance Portability and
Accountability Act (HIPAA) requirements including the following:
1. The Contractor must not share any protected health data and
information provided by the Department that falls within i -IIPAA
requirements except to a subcontractor as appropriate under this
agreement.
2. The Contractor must require the subcontractor not to share any
protected health data and information from the Department that
falls under H1PAA requirements in the terms and conditions of the
subcontract.
3. The Contractor must only use the protected health data and
information for the purposes of this agreement.
4. The Contractor must have written policies and procedures
addressing the use of protected health data and information that
falls under the HIPAA requirements. The policies and procedures
must meet all applicable federal and state requirements including
the HIPAA regulations. These policies and procedures must
include restricting access to the protected health data and
information by the Contractor's employees.
5. The Contractor must have a policy and procedure to report to the
Department unauthorized use or disclosure of protected health data
and information that falls under the HIPAA requirements of which
the Contractor becomes aware.
6. Failure to comply with any of these contractual requirements may
result in the termination of this agreement in accordance with Part
11, Section V. Termination.
7. In accordance with H1PAA requirements, the Contractor is liable for
any claim, loss or damage relating to unauthorized use or
disclosure of protected health data and information received by the
Contractor from the Department or any other source.
IV. Financial Requirements
Operating Advance
The Department will not issue an operating advance under this
Agreement.
B. Reimbursement Method
The Contractor will make prepayments equal to the department's
approved prepayment schedule. The prepayments will be monthly except
that the initial prepayment will be for the months of October and November
combined, and there will be no prepayment in November.
Prepayments will be adjusted quarterly based upon expenditure reports
for the prior quarter. Expenditure reporting procedures are described in
Attachment B to this agreement.
gr Reimbursement from the Department is based on the understanding that
Department funds will be paid up to the total Department allocation as
agreed to in the approved budget. Department funds are first source after
the application of fees and earmarked sources unless a specific local
A.
match condition exists. Attachment A to this agreement contains specific
local match requirements.
C. Revenues and Expenditures Report Form
Financial Status Reports (FSRs) (DCH-0384 forms) are no longer
required. The Contractor shall report expenditures on the Revenues and
Expenditures Report (RER) Form as indicated in Attachment B, and
submit this form to:
Michigan Department of Community Health,
Bureau of Finance
Accounting Division, Expenditure Operations Section,
P.O. Box 30720, Lansing, Michigan 48909
This RER form must be submitted on a quarterly basis, no later than thirty
(30) days after the close of each fiscal quarter. The quarterly Revenues
and Expenditures Report Forms must reflect total program expenditures,
regardless of the source of funds. Attachment B contains the RER form.
Failure to meet financial reporting responsibilities as identified in this
agreement may result in withholding future payments.
D. Reimbursement Mechanism
All contractors are encouraged to sign up through the on-line vendor
registration process to receive all State of Michigan payments as
Electronic Funds Transfers (EFT)/Direct Deposits.
E. Final Obligations and Financial Status Report Requirements
1. Preliminary Close Out Report
A Preliminary Close Out Report, based on annual guidelines, must
be submitted by the due date using the format provided by the
Department's Accounting Division. The Contractor must provide an
estimate of total expenditures for the entire agreement period. The
information on the report will be used to record the Department's
year-end accounts payables and receivables for this agreement.
2. Final Revenues and Expenditures Report Form
Final Revenues and Expenditures Report Forms are due 76 days
following the end of the fiscal year or agreement period. The final
RER Report must be clearly marked "Final". Final RER Reports not
received by the due date may result in the loss of funding
requested on the Preliminary Close Out Report and may result in
the potential reduction in the subsequent year's Agreement
amount.
F. Unobligated Funds
Any unobligated balance of funds held by the Contractor at the end of the
agreement period will be returned to the Department or treated in
accordance with instructions provided by the Department.
V. Agreement Termination
The Department may cancel this Agreement without further liability or penalty to
the Department for any of the following reasons:
A. This agreement may be terminated by either party by giving thirty (30)
days written notice to the other party stating the reasons for termination
and the effective date.
B. This agreement may be terminated on thirty (30) days prior written notice
upon the failure of either party to carry out the terms and conditions of this
agreement, provided the alleged defaulting party is given notice of the
alleged breach and fails to cure the default within the thirty (30) day
period.
C. This agreement may be terminated immediately if the Contractor or an
official of the Contractor or an owner is convicted of any activity
referenced in Section 111.D. of this agreement during the term of this
agreement or any extension thereof.
VI. Final Reporting Upon Termination
Should this agreement be terminated by either party, within thirty (30) days after
the termination, the Contractor shall provide the Department with all financial,
performance and other reports required as a condition of this agreement. The
Department will make payments to the Contractor for allowable reimbursable
costs not covered by previous payments or other state or federal programs. The
Contractor shall immediately refund to the Department any funds not authorized
for use and any payments or funds advanced to the Contractor in excess of
allowable reimbursable expenditures. Any dispute arising as a result of this
agreement shall be resolved in the State of Michigan.
VII. Severability
If any provision of this agreement or any provision of any document attached to
or incorporated by reference is waived or held to be invalid, such waiver or
invalidity shall not affect other provisions of this agreement.
VIII. Amendments
Any changes to this agreement will be valid only if made in writing and accepted
by all parties to this agreement. Any change proposed by the Contractor which
would affect the Department funding of any project, in whole or in part in Part 1,
Section 2.C. of the agreement, must be submitted in writing to the Department for
approval immediately upon determining the need for such change.
IX. Liability
A. All liability to third parties, loss, or damage as a result of claims, demands,
costs, or judgments arising out of activities, such as direct service delivery,
to be carried out by the Contractor in the performance of this agreement
shall be the responsibility of the Contractor, and not the responsibility of
the Department, if the liability, loss, or damage is caused by, or arises out
of, the actions or failure to act on the part of the Contractor, any
subcontractor, anyone directly or indirectly employed by the Contractor,
provided that nothing herein shall be construed as a waiver of any
governmental immunity that has been provided to the Contractor or its
employees by statute or court decisions.
B. All liability to third parties, loss, or damage as a result of claims, demands,
costs, or judgments arising out of activities, such as the provision of policy
and procedural direction, to be carried out by the Department in the
performance of this agreement shall be the responsibility of the
Department, and not the responsibility of the Contractor, if the liability,
loss, or damage is caused by, or arises out of, the action or failure to act
on the part of any Department employee or agent, provided that nothing
herein shall be construed as a waiver of any governmental immunity by
the State, its agencies (the Department) or employees as provided by
statute or court decisions.
C. In the event that liability to third parties, loss, or damage arises as a result
of activities conducted jointly by the Contractor and the Department in
fulfillment of their responsibilities under this agreement, such liability, loss,
or damage shall be borne by the Contractor and the Department in
relation to each party's responsibilities under these joint activities,
provided that nothing herein shall be construed as a waiver of any
governmental immunity by the Contractor, the State, its agencies (the
Department) or their employees, respectively, as provided by statute or
court decisions.
X. Conflict of Interest
The Contractor and the Department are subject to the provisions of 1968 PA 317,
as amended, MCL 15.321 et seq, MSA 4.1700(51) et seq, and 1973 PA 196, as
amended, MCL 15.341 et seq, MSA 4.1700 (71) et seq.
XI. State of Michigan Agreement
This is a State of Michigan Agreement and is governed by the laws of Michigan.
Any dispute arising as a result of this agreement shah be resolved in the State of
Michigan.
XII Confidentiality
Both the Department and the Contractor shall assure that medical services to
and information contained in medical records of persons served under this
agreement, or other such recorded information required to be held confidential by
federal or state law, rule or regulation, in conneOtion with the provision of
services or other activity under this agreement shall be privileged
communication, shall be held confidential, and shall not be divulged without the
written consent of either the patient or a person responsible for the patient,
except as may be otherwise required by applicable law or regulation. Such
information may be disclosed in summary, statistical, or other form, which does
not directly or indirectly identify particular individuals.
MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
FY 03/04 AGREEMENT ADDENDUM A
1. This addendum adds the following section to Part I and Renumbers existing 11 Special
Certification to 12 and existing 12 Signature Section to 13; and adds the following changes
to the Grant Agreement Between Michigan Department of Community Health and Oakland
County Health Division for Substance Abuse Services for the period 10/1/03 Through
9/30/04:
Part I
11. Agreement Exceptions and Limitations
Notwithstanding any other term or condition in this Agreement including, but not limited to,
any provisions related to any services as described in the Annual Action Plan,
any Contractor (Oakland County) services provided pursuant to this Agreement,
or any limitations upon any Department funding obligations herein, the Parties
specifically intend and agree that the Contractor may discontinue, without any penalty
or liability whatsoever, any Contractor services or performance obligations under this
Agreement when and if it becomes apparent that State or Department funds for any
such services will be no longer available. Notwithstanding any other term or
condition in this Agreement, the Parties specifically understand and agree that no
provision in this Agreement shall operate as a waiver, bar or limitation of any kind, on any
legal claim or right the Contractor may have at any time under any Michigan constitutional
provision or other legal basis (e.g., any Headlee Amendment limitations) to challenge
any State or Department program funding obligations; and, the parties further agree
that no term or condition in this Agreement is intended and no such provision shall
be argued to state or imply that the Contractor voluntarily assumed or undertook to
provide any services as described in the Annual Action Plan, and thereby, waived any
rights the Contractor may have had under any legal theory, in law or equity,
without regard to whether or not the Contractor continued to perform any services
herein after any State or Department funding ends.
2. This addendum modifies the following sections of Part II, General Provisions:
Part ll
I. Responsibilities-Contractor
I. Software Compliance. This section will be deleted in its entirety
and replaced with the following language:
The Michigan Department of Community Health and the County of
Oakland will work together to determine and avoid potential computer
systems problems.
III. Assurances
A. Compliance with Applicable Laws. This first sentence of this
paragraph will be stricken in its entirety and replace with the following language:
The Contractor will comply with applicable Federal and State laws, and
lawfully enacted administrative rules or regulations, in carrying out the
terms of this agreement.
I. Health Insurance Portability and Accountability Act.
The provisions in this section shall be deleted In their entirety and
replaced with the following language:
Contractor agrees that it will comply with the Health Insurance
Portability and Accountability Act of 1996, and the lawfully enacted and
applicable Regulations promulgated thereunder.
IX. Liability. Paragraph A. will be deleted in its entirety and replaced with the
following language.
A. Except as otherwise provided for in this Contract, all liability, loss, or
damage as a result of claims, demands, costs, or judgments arising out of
activities to be carried out pursuant to the obligations of the Contractor
under this Contract shall be the responsibility of the Contractor and not
the responsibility of the Department, if the liability, loss, or damage is caused
by, or arises out to the actions or failure to act on the part of the Contractor, its
employees, officers or agents. Nothing therein shall be construed as a waiver
of any governmental immunity for the Contractor, its agencies,
employees, or Oakland County, as provided by statute or modified by court
decisions.
3. Special Certification
The individual or officer signing this agreement certifies by his or her signature
that he or she is authorized to sign this agreement on behalf of the
Department or the Contractor.
Signature Date
Signature Section:
For the MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
Date
For the CONTRACTOR
Thomas A. Law, Chairman, Oakland County Board of Commissioners
Name and Title
ATTACHMENT A
STATEMENT OF WORK
1. General Statement of Work
The general responsibilities of the coordinating agency (CA) under this
Agreement, based on P.A. 368 of 1978, as amended, are to:
a. Develop comprehensive plans for substance abuse treatment and
rehabilitation services and prevention services consistent with guidelines
established by the Department.
b. Review and comment to the Department on applications for licenses
submitted by local treatment, rehabilitation, and prevention organizations.
c. Provide technical assistance for local substance abuse service
organizations
d. Collect and transfer data and financial information from local organizations
to the Department.
e. Submit an annual budget request to the Department for use of state
administered funds for its city, county, or region for substance abuse
treatments and rehabilitation services and prevention services in
accordance with guidelines established by the Department
f. Make contracts necessary and incidental to the performance of the
Agency functions. The contracts may be made with public or private
agencies, organizations, associations, and individuals to provide for
substance abuse treatment and rehabilitation services and prevention
services
g. Annually evaluate and assess substance abuse services in the city,
county, or region in accordance with guidelines established by the
Department and federal goals.
2. Annual Action Plan Guidelines (AAPGs) and Annual Action Plan
The CA will carry out its responsibilities under this Agreement consistent with the
CA's FY 2005 Annual Action Plan (AAP) submitted in response to the FY 2005
AAPGs, as revised and approved in writing by the Department. The CA's
approved AAP is incorporated into this Agreement by reference. The
methodologies and program content to be used in achieving the CA's
responsibilities under this Agreement must be consistent with the approved AAP.
Page 1 of 21 September 2004
3. Substance Abuse Prevention and Treatment (SAPT) Block Grant
Federal requirements deriving from Public Law 102-321, as amended by Public
Law 106-310, and federal regulations in 45 CFR Part 96 are pass-through
requirements. Most federal Substance Abuse Prevention and Treatment (SAPT)
Block Grant requirements applicable to states are passed on to CAs.
42 CFR Parts 54 and 54a, and 45 CFR Parts 96, 260 and 1050, pertaining to the
final rules for the Charitable Choice Provisions and Regulations, are applicable to
CAs as stated elsewhere in this Agreement.
SAPT Block Grant requirements also apply to the Michigan Department of
Community Health (MDCH) administered state funds, unless a written exception
is obtained from MDCH. Sections from PL 102-321, as amended, that apply to
CAs and contractors include; 1921(b); 1922 (a)(1)(2); 1922(b)(1)(2); 1923;
1923(a)(1) and (2), and 1923(b); 1924(a)(1)(A) and (B); 1924(c)(2)(A) and (B);
1927(a)(1) and (2), and 1927(b)(1); 1927(b)(2); 1928(b) and (c); 1929;
1931(a)(1)(A), (B), (C), (D), (E) and (F); 1932(b)(1); 1942(a); 1943(b); 1947(a)(1)
and (2).
Selected specific requirements applicable to CAs are as follows:
• Block Grant funds shall not be used to pay for inpatient hospital services
except under condition specified in federal law.
• Funds shall not be used to make cash payments to intended recipients of
services.
• Funds shall not be used to purchase or improve land, purchase, construct,
or permanently improve (other than minor remodeling) ally building or any
other facility, or purchase major medical equipment.
• Funds shall not be used to satisfy any requirement for the expenditure of
non-Federal funds as a condition for the receipt of Federal funding.
• Funds shall not be used to provide individuals with hypodermic needles or
syringes so that such individuals may use illegal drugs.
• Funds shall not be used to enforce State laws regarding the sale of
tobacco products to individuals under the age of 18.
• Funds shall not be used to to pay the salary of an individual at a rate in
excess of Level! of the Federal Executive Schedule, or currently
$174,500.
4. Match Rules
Pursuant to Section 6213 of Public Act No. 368 of 1978, as amended, Michigan
has promulgated match requirement rules for CA budgets. Rules 325.4151
through 325.4153 appear in the 1981 Annual Administrative Code Supplement.
In brief, the rule defines allowable matching funds sources and states that the
allowable match must equal at least ten percent of each comprehensive CA
budget (Department-administered non-capitated funds made available through
Page 2 of 21 September 2004
• /
this Agreement, plus local funds, plus fees and collections) less direct Federal
and other State funds, Match requirements apply both to budgeted funds and
actual expenditures.
"Fees and collections" as defined in the Rule include only those fees and
collections that are associated with services paid for by the CA.
If the CA is found not to be in compliance with Match requirements, or cannot
provide reasonable evidence of compliance, the Department may withhold
payment or recover payment in an amount equal to the amount of the Match
shortfall.
5. Reporting Fees and Collections Revenues
The CA is required to report all fees and collections revenue received by the CA
and all fees and collections revenue received and reported by its contracted
services providers on the Revenue and Expenditures Report Form (see
Attachment B to this Agreement). "Fees and collections" are as defined in the
Annual Administrative Code Supplement, Rule 325.4151 and in the Match Rule
section of this Attachment.
6. Management of Department-Administered Funds
Department-administered funds, including SAPT Block Grant, State General
Funds, and Medicaid funds, are first sources after the application of available first
and third party revenues, consistent with requirements in applicable Department
contracts. The CA shall manage all Department-administered funds under its
control in such a way as to assure reasonable balance among the separate
requirements for each funds source.
7. Staff Qualifications and Professional Development
a. The CA shall assure that, for network providers, all direct service staff
providing Access, Assessment and Referral (AAR) services, and all
provider clinical staff, whether on a salaried or contractual basis, have
passed the Fundamentals of Substance Abuse Counseling (FSAC) or the
Fundamental of Alcohol and Other Drug Problems (FAODP) examination.
Individuals who possess any of the following are exempt from the above
requirement:
• Current licensure as a physician or psychologist;
• Valid Certified Addictions Counselor (CAC) certification;
• A Master's degree in counseling, social work, guidance and
counseling, or clinical psychology plus 2080 hours of supervised
professional experience in substance abuse treatment; or
Page 3 of 21 September 2004
• Other specialty certification or membership credentials in
addictions, such as Addiction Certification for Counselors under the
National Board of Certified Counselors.
A one-time, six-month waiver may be requested from the Michigan
Certification Board for Addiction Professionals (MCBAP) to allow time to
schedule and prepare for the exam and/or certification, for each staff in
the process of applying. The waiver, if granted, will allow staff to perform
their duties under the supervision of a staff person who is already
appropriately credentialed while preparing for an exam and/or certification.
b. The CA shall require all treatment provider panel members to establish
and maintain a credentials file on all salaried or contractual staff who are
providing clinical services.
The credentials file must include, at minimum: academic history with proof
of completion; internship, practicum and clinical experience that is
supervised, with area of clinical practice, age group and/or special skills
learned; employment experience in the form of resume'; copies of
professional licenses, certification and registrations; current list of "in-
service" training completed, including other professional training
experiences pertinent to clinical practice. The credentials file will serve as
a support to clinical privileges practiced, which will be listed by date
granted in the credentials file. The CA is responsible for maintaining the
currency of its own credentials files. The CA is responsible for auditing
and monitoring the currency of its provider credentials files on an annual
basis. A sampling method may be used.
c. The CA must ensure that criminal background checks are conducted as a
condition of employment for its own potential employees and for network
provider potential employees. This requirement is not intended to imply
that a criminal record should necessarily bar employment.
d. The CA shall require professional development of counselors and all
health care workers relative to HIV/AIDS prevention and the prevention of
other serious communicable diseases.
Sliding Fee Scale
The CA shall implement a sliding fee scale. The scale shall be utilized in all
treatment programs, including the Access, Assessment and Referral (AAR)
agency.
By April 1, 2005, the CA must adopt written policies and procedures for
determining when an individual has no ability to pay for services and for gr
determining when payment liability is to be waived.
Page 4 of 21 September 2004
Financial information needed to determine ability to pay (financial responsibility)
must be reviewed every six months or at a change in an individual's financial
status.
The CA sliding fee scale must be applied to all persons (except Medicaid,
MIChild, and ABW recipients) seeking substance abuse services in funded
treatment providers. The CA may apply the sliding fee scale to AAR services, or
the CA may choose to charge no fees for AAR services. if the CA chooses to
charge for AAR services, the same sliding fee scale as applied to treatment
services must be applied to MR services.
Services may not be denied because of inability to pay. If a person's income falls
within the CA's regional sliding fee scale, clinical need must be determined
through the standard assessment and patient placement process. If a financially
and clinically eligible person has third party insurance, that insurance must be
utilized to its full extent. Then, if benefits are exhausted, or if the person needs a
service not fully covered by that third party insurance, or if the co-pay or
deductible amount is greater than the person's ability to pay, Community Grant
funds may be applied. Community Grant funds may not be denied solely on the
basis of a person having third party insurance.
With respect to MR services, all fees for in-person, teleconference and/or
telephone assessments within a region must be the same. A CA that charges for
an in-person assessment must also charge for telephone and teleconference
assessments.
With respect to Department-administered funds, the CA is a payer of last resort.
The CA must have written policies and procedures to be used by network
providers in determining an individual's ability to pay, and in identifying all other
liable third parties. The CA must also have policies and procedures for
monitoring providers and for sanctioning noncompliance.
9. 12-Month Availability of Services
The CA shall assure that, for any subcontracted treatment or prevention service,
each subcontractor maintains service availability throughout the fiscal year to
persons who do not have the ability to pay.
10. Licensure of Subcontractors
The CA shall enter into subcontracts for prevention and treatment services only
with providers licensed as required by Section 6231 of P.A. 368 of 1978, as
amended. The subcontractor must be licensed for the service category funded.
The CA must ensure that network providers residing and providing services in
bordering states meet all applicable licensing and certification requirements
within their states, that staff are credentialed per the requirements of this
Agreement, and that providers are accredited per the requirements of this
Agreement.
Page 5 of 21 September 2004
11. Accreditation of Subcontractors
The CA shall enter into subcontracts for treatment services only with providers
accredited by one of the following accrediting bodies: Joint Commission on
Accreditation of Health Care Organizations (JCAH0); Commission on
Accreditation of Rehabiiitation Facilities (CARF); Council on Accreditation of
Services for Families and Children (COA); American Osteopathic Association
(AOA); or National Committee on Quality Assurance (NCQA). The CA must
determine compliance through review of original correspondence from
accreditation bodies to providers.
12. Satisfaction Surveys
The CA shall assure that satisfaction surveys of persons receiving treatment are
required of all subcontractors providing treatment and receiving state-
administered funds. Surveys may be conducted by individual providers or may
be conducted centrally by the CA. If individual providers conduct the satisfaction
surveys, the CA shall obtain evidence of provider compliance. At least once
each year, surveys must be conducted of clients of each provider. Clients may
be active clients or clients discharged up to 12 months earlier. Surveys may be
conducted by mail, telephone, or face-to-face. The CA must compile findings
and results of client satisfaction surveys for all providers, and must make findings
and results available to the public.
13. SAMHSA/DHHS License
The federal awarding agency, Substance Abuse and Mental Health Services
Administration/Department of Health and Human Services (SAMHSA/DHHS),
reserves a royalty-free, nonexclusive and irrevocable license to reproduce,
publish or otherwise use, and to authorize others to use, for federal government
purposes: (a) The copyright in any work developed under a grant, subgrant, or
contract under a grant or subgrant; and (b) Any rights of copyright to which a
grantee, subgrantee or a contractor purchases ownership with grant support.
14. Subcontracts with Hospitals
Funds made available through the Department shall not be made available to
public or private hospitals which refuse, solely on the basis of an individual's
substance abuse or substance dependence, admission or treatment for
emergency medical conditions.
15. Notice of Plan Submission
Where conditions of funding require the submission of a substance abuse service
plan, the applicant shall concurrently publicize, for at least one day, notice that
submission has occurred and that the substance abuse service plan is available
for review throughout the period of funding.
Page 6 of 21 September 2004
16. Residency in CA Region
The CA may not limit access to the programs and services funded by this
Agreement only to the residents of the CA's region, because the funds provided
by the Department under this Agreement come from federal and statewide
resources. Members of Federal and State-identified priority populations must be
given the required access to MR and treatment services regardless of their
residency. However, the CA may give its residents priority in obtaining services
funded under this Agreement when the actual demand for services by residents
eligible for services under this Agreement exceeds the capacity of the programs
funded under this Agreement, as long as admission requirements regarding
priority populations are adhered to
17. Out-of- Network and Out-of-Region Services
The CA must have written policies and procedures for authorizing and
purchasing treatment services from out-of-network and out-of-region providers
for residents of the CA region who need care from such providers.
18. Cooperation with External Medicaid Evaluation
The CA is expected to cooperate with Department efforts in external evaluation
of Medicaid services. The CA is expected to ensure that CA-funded providers
will provide necessary data and will facilitate access to individuals' files and other
records as required.
19. Reimbursement Rates for Community Grant and Medicaid Services
The CA must pay the same rate when purchasing the same service from the
same provider, regardless of whether the services are paid for by Community
Grant funds or by Medicaid funds.
20. Minimum Criteria for Reimbursing for Services to Persons with Co-
Occurring Disorders
Department funds made available to the CA through this Agreement, and that are
allowable for treatment services, may be used to reimburse providers for mental
health treatment services (in addition to substance abuse treatment services) to
persons with co-occurring substance abuse and mental health disorders. _
The CA may reimburse a CMHSP or PIHP for substance abuse treatment
services for such persons who are receiving mental health treatment services
through the CMHSP or P1HP. The CA may also reimburse a provider, other than
a CMHSP or P1HP, for substance abuse treatment provided to persons with co-
occurring disorders. As always when reimbursing for substance abuse
treatment, the CA must have a contract with the CMHSP (or other provider), and
September 2004 f)ge 7 of 21
the CMHSP (or other provider) must meet all minimum qualifications, including
licensure, accreditation and data reporting.
21. Persons Associated with the Corrections System
When the CA or its Access, Assessment and Referral agency receives referrals
from the Michigan Department of Corrections (MDOC), the CA shall handle such
referrals as per standard contract requirements. This would include determining
financial and clinical eligibility, authorizing care as appropriate, applying
admissions preferences, and other steps. MDOC referrals may come from
MDOC's substance abuse gatekeeper, from probation or parole agents, or from
Central Office staff.
When persons who are on parole or probation seek treatment on a voluntary
basis from the CA's AAR or from a panel provider, these self-referrals must be
handled like any other self-referral to the MDCH-funded network. AAR or
provider staff may seek to obtain consent Agreement releases to communicate
with a person's probation or parole agent but in no instance may this be
demanded as a condition for admission or continued stay.
MDOC purchases treatment services from providers through its Substance
Abuse Services Program and through its Office of Community Corrections
(OCC). The CA may also purchase services from MDOC-funded providers,
including treatment services and/or room and board services. The CA may not
supplement MDOC Substance Abuse Service Program rates, except for room
and board using State Disability Assistance (SDA) funds under the standard
requirements for the use of SDA funds.
In no case may CA funds constitute duplication of payment. It is recommended
that when the CA contracts with providers that also receive MDOC funds
(including OCC funds), the CA contracts should contain explicit language
prohibiting duplication of payment.
22. State Disability Assistance (SDA)
MDCH will continue to allocate State Disability Assistance (SDA) funding and to
delegate management of this funding to the CA. The SDA funding will be
identified in the CA's allocation letter. The CA is responsible for allocating these
funds to qualified providers. Minimum provider qualifications are Department of
Community Health licensure as a Residential treatment provider and
accreditation by one of the five approved accreditation bodies (identified
elsewhere in this Agreement). A provider may be located within the CA's region
or outside of the region. SDA funds shall not be used to pay for room and board
in conjunction with sub-acute detoxification services.
When a client is determined to be eligible by the Family Independence Agency
(FIA) for SDA funding, the CA where the provider is located must arrange for
assessment and authorization for SDA room and hnnrri funding and must
Page 8 of 21 September 2004
reimburse for SDA expenditures based on billings from contracted providers in its
region, consistent with CA/provider contracts. In addition, the CA may authorize
such services for its own residents at providers within or outside the region.
The CA shall not refuse to authorize SDA funds for support of an individual's
treatment solely on the basis of the individual's current or past involvement with
the criminal justice system. Qualified providers may be reimbursed up to twenty-
three dollars ($23.00) per day for room and board costs for SDA-eligible persons
during their stays in Residential treatment.
To be eligible for SDA funding for room and board services in a substance abuse
treatment program, a person must be determined to be eligible for an incidental
allowance through the HA; assessed by the regional AAR to be in need of
residential treatment services; authorized by the CA (or AAR) for residential
treatment when the CA expects to reimburse the provider for the treatment; and
in residence in a residential treatment program each day that SDA payments are
made.
The CA must have a contractual relationship with a provider in order to provide
SDA funds.
23. Case Management Reimbursement
The cost of case management services may be built into a licensed AJAR,
Screening, Assessment, Referral and Follow-up (SARF), or treatment service
reimbursement rate, including those services provided at designated women's
services programs.
The CA may choose to pay for case management as a separate service during
FY 2005, on a pilot basis. Case management services and provider agencies
must meet the criteria stated in the FY 2005 AAPG, unless the CA obtains a
written waiver from the Department.
24. Persons Involved With FIA
The CA must work with the Family Independence Agency office(s) in its region
on issues related to prevention, access, assessment and treatment of persons
involved with FIA, including families in the child welfare system and public
assistance recipients.
25. Primary Care Coordination
The CA must take all appropriate steps to assure thatsubstance abuse treatment
services are coordinated with primary health care. In the case of CAs that are
under contract with Prepaid Inpatient Health Plans (PIHPs)for the Medicaid
substance abuse program, CAs are reminded that coordination efforts must be
consistent with these contracts.
Page 9 of 21 September 2004
26. Media Campaigns
The CA shall not finance any media campaign using MDCH funding unless
authorized in writing by MDCH. Advertising about the availability of services
within the CA region is not considered a media campaign.
27. Notice of Funding Excess or Insufficiency
The CA must advise the Department in writing by May 1 if the amount of
Department funding may not be used in its entirety or appears to be insufficient.
28. Subconttactor Information to be Retained at CA
a. Budgeting Information for Each Service
b. Documentation of How Fixed Unit Rates Were Established
The CA shall maintain documentation regarding how each of the fixed unit
rates used in its contracts was established.
c. Indirect Cost Documentation
( ;2441c 1-61'
The CA shall review subcontractor indirect cost documentation in
accordance with OMB Circular A-87 or A-122, as applicable.
d. Equipment Inventories
The CA must follow record keeping and reporting procedures, as indicated
in Part 1 , 2.B., and in Attachment B to this Agreement.
Fidelity Bonding Documentation
The CA shall maintain fidelity bonding documentation.
29. General Reporting Requirements
Requirements concerning specific reports are contained elsewhere in the
Agreement, including in Attachment C. The following requirements pertain to
reports that are to be submitted to the Department's Office of Drug Control
Policy.
a. Each report must be submitted by the specified due date. Reports
postmarked on the due date or earlier will be considered timely, if sent first
class, expedited delivery by U.S. mail, or the equivalent by commercial
delivery service. Reports successfully e-mailed or faxed by the due date
are considered timely.
September 2004 Page 10 of 21
b. Reports must be sent to the addressee specified in this Agreement.
Reports that are not sent to the specified addressee are subject to being
determined not timely or not received.
c. Reports must be submitted on the form and in the format specified in this
Agreement (if form and format are specified).
30. Reimbursement for Primary Care with HIV Early Intervention Program (EIP)
Funds
HIV Early Intervention Program funds shall not be used to purchase primary care
unless such use is approved in writing by the Department.
31. Sentinel Events
Requirements for reporting data on Sentinel Events are contained in Attachment
F. Consistent with that material, the CA must ensure that a root cause analysis
or investigation takes place following the identification of each sentinel event.
The CA must then ensure that a plan of action be developed and implemented to
prevent further occurrence of the sentinel event. The plan must identify who is
responsible for implementing the plan, and how implementation will be
monitored. Alternatively, the CA may prepare a rationale for not pursuing a
preventive plan.
32. Clinical Eligibility: DSM IV-TR Diagnosis
In order to be eligible for services, an individual must be found to meet the
criteria for one or more selected substance use disorders found in the Diagnostic
and Statistical Manual of Mental Disorders (DSM IV-TR). These disorders are
listed below:
303.90
305.00
303.00
291.80
304.40
305.70
292.89
292.00
304.30
305.20
292.89
304.20
305.60
292.89
292.00
304.50
Alcohol Dependence
Alcohol Abuse
Alcohol Intoxication
Alcohol Withdrawal
Amphetamine Dependence
Amphetamine Abuse
Amphetamine Intoxication
Amphetamine Withdrawal
Cannabis Dependence
Cannabis Abuse
Cannabis Intoxication
Cocaine Dependence
Cocaine Abuse
Cocaine Intoxication
Cocaine Withdrawal
Hallucinogen Dependence
Page 11 of 21 September 2004
305.30
292.89
304.60
305.90
292.89
304.00
305.50
292.89
292.00
304.60
305.90
292.89
304.10
305.40
292.89
292.00
304.90
305.90
292.89
292.00
Hallucinogen Abuse
Hallucinogen Intoxication
Inhalant Dependence
Inhalant Abuse
Inhalant Intoxication
Opioid Dependence
Opioid Abuse
Opioid Intoxication
Opioid Withdrawal
Phencyclidine Dependence
Phencyclidine Abuse
Phencyclidine intoxication
Sedative, Hypnotic, or Anxiolytic Dependence
Sedative, Hypnotic, or Anxiolytic Abuse
Sedative, Hypnotic, or Anxiolytic Intoxication
Sedative, Hypnotic, or Anxiolytic Withdrawal
Other (or Unknown) Substance Dependence
Other (or Unknown) Substance Abuse
Other (or Unknown) Substance Intoxication
Other (or Unknown) Substance Withdrawal
33. Claims Management System
The CA shall make timely payments to all providers for clean claims. This
includes payment at 90% or higher of clean claims from network providers within
60 days of receipt, and 99% or higher of all clean claims within 90 days of
receipt.
A clean claim is a valid claim completed in the format and time frames specified
by the CA and that can be processed without obtaining additional information
from the provider. It does not include a claim from a provider who is under
investigation for fraud or abuse, or a claim under review for medical necessity. A
valid claim is a claim for services that the CA is responsible for under this
Agreement. It includes services authorized by the CA.
The CA must have a provider appeal process to promptly and fairly resolve
provider-billing disputes.
34. Cultural Competence
CA must have a written cultural competency plan implemented in practice at their
agency and at all provider agencies. The plan must include:
a. The CA's identification and assessment of the cultural needs of potential
and active clients based on population served.
b. The CA's identification of how access to services is facilitated for persons
with diverse cultural backgrounds and LEP.
Page 12 of 21 September 2004
c. The CA's identification standards for the recruitment and hiring of
culturally competent staff members.
c. The CA's identification of how ongoing staff training needs in cultural
competency will be assessed and met and the evidence that staff
members receive training.
d. The CA's process for ensuring that contractual providers comply with all
applicable requirements concerning the provision of culturally competent
services.
e. The CA's process for annually assessing its compliance with the CA's
cultural competence plan.
35. Adult Benefit Waiver
In consideration for accepting the federal funding pushed to the Coordinating
Agency (CA) for the State Medical Program (SMP) eligibles under an approved
Health Insurance Flexibility and Accountability (HIFA) Adult Benefit Waiver
(ABW), the CA agrees to redirect existing state contracted general fund dollars to
match the ABW federal FMAP funds (Title XXI State Children's Health Insurance
Program) and carry out the associated substance abuse program requirements.
Program requirements are contained in this contract and in the Department's
Medicaid Provider Manual's chapter on Adult Benefits Waiver I, which is
available at the Department's web site. The ABW program is contingent on
continued federal approval of the program.
The total ABW funding applied to program expenditures (federal plus general
fund match) shall not exceed $3.80 per enrolled eligible member per month.
MDCH shall push the federal portion of the eligible amount to the CA (PEPM X
$3.80 X .6912) based on program enrollment. The amount of general fund dollars
applied by the CA to program costs shall equal .3088 percent of the total PEPM
during the contract g year following the date of program initiation. In the event that
program costs are le—S-i-thart-the—federal and state applicable match requirement
amount, the CA shall retain the balance as local dollars. In the event that
program costs are greater than the federal and state match amount, the CA may
use other State Agreement funds budgeted for treatment in this Agreement,
consistent with requirements pertaining to the use of these other State
Agreement funds.
ABW Covered and Discretionary Services
ABW covered and discretionary services, as contained in the Medicaid Provider
Manual, are listed below.
Page 13 of 21 September 2004
Covered Services:
• Initial assessment, diagnostic evaluation, referral and patient placement;
• Outpatient Treatment;
• Intensive Outpatient Treatment; and
• Federal Food and Drug Administration (FDA) approved pharmacological
supports for Levo-Alpha-Acetyl-Methadol (LAAM) and Methadone only.
ABW Discretionary Services:
• Other substance abuse services may be provided, at the discretion of the
CA, to enhance outcomes.
The CA is required to pay for medically necessary and requested covered
services, within applicable benefit limitations, for the enrolled population in
excess of the combined federal and applicable match funds. The CA may apply
available SAPT Block Grant funds and state general funds to pay for ABW
covered services when ABW funds (federal and state shares combined) have
been exhausted.
The CA may also choose to pay for non-covered and discretionary services for
ABW beneficiaries with other available funds. Any use of SAPT Block Grant and
state general funds to pay for discretionary or non-covered services must be
consistent with contract provisions applicable to these funds.
ABW beneficiaries who receive ABW covered services shall be treated according
to all applicable requirements of the ABW program, regardless of source of funds
for these services. ABW beneficiaries who receive ABW discretionary services
shall be treated according to applicable ABW program requirements when the
source of funds is ABW funds.
The CA may not charge fees or co-pays to ABW beneficiaries for covered
services or for discretionary services purchased with ABW funds.
ABW funds may not be used to purchase care for persons who are residents in
institutions for mental diseases (IMDs).
Access Timeliness
Beneficiaries must be admitted to treatment within seven days following an
assessment, and must receive an assessment within five days of referral or
presentation. Access must be expedited when appropriate based on
beneficiaries' presenting characteristics.
Page 14 of 21 September 2004
Appeals by ABW Enrollees
ABW beneficiaries must be provided written notice of right to appeal proposed
denials, reductions, suspensions or terminations of covered services through the
administrative hearing process, as described in All Provider Bulletin 03-10.
Encounter Data and Quality Improvement Data
Enrollees who receive substance abuse services must be entered into the
Substance Abuse Statewide Client Data System following the coding instructions
in the data reporting specifications.
For the required reporting of encounters for ABW Eligible clients, the CA will
report these encounters via the 837 as follows:
2000B - Subscriber Hierarchical Level
SBR — Subscriber Information
SBRO4 — Insured Group Name. Use "ABW" for Adult Benefits Waiver
The combined federal share and the GF match share amounts should be
reported separately by using the Primary, Secondary, and Tertiary Payer
guidelines under the 2000B Loop (Subscriber Hierarchical Loop SBRO1 Data
Element — Payer Responsibility Sequence Number Code. These codes were
covered at the H1PAA Readiness Seminars in 2003.
Revenue and Expenditures Reporting
Revenue and expenditures reporting requirements are contained in Attachment B
to this Agreement.
Benefit Limits
This is a limited benefit program. Utilization control procedures consistent with
best practice standards and the three criteria stated below, must be used. The
CA may provide or authorize ABW covered and discretionary services only when
these services:
• meet the medical necessity criteria contained in this Agreement;
• are based on individualized determination of need; and
• meet AAR service requirements contained in this Agreement, including a
level of care determination based on an evaluation of the six assessment
dimensions of the current ASAM Patient Placement Criteria.
The CA must assure that all persons admitted to treatment have an
individualized plan that emphasizes appropriate treatment and recovery.
Page 15 of 21 September 2004
The CA shall not discontinue or interrupt ABW services when ABW beneficiaries
are admitted to treatment, have exhausted their ABW benefit, and are financially
and clinically eligible for continued treatment under the Block Grant program.
a. Initial Assessment, Diagnostic Evaluation, Referral and Patient Placement
The CA will perform a screening and when warranted by the screening
results, the CA will perform an initial assessment and a diagnostic
evaluation for ABW beneficiaries who meet medical necessity criteria.
The CA will make referrals and/or patient placements based on individual
need.
The CA may perform or pay for no more than one assessment for a
beneficiary in any six-month period.
b. Outpatient Treatment
The CA may authorize up to 15 outpatient units in a twelve-month period
based on medical necessity criteria, individualized determination of need,
AAR service requirements, and best practice standards.
The CA may authorize additional units based on these same criteria plus:
• The beneficiary's commitment to treatment based on participation
and attendance;
• Progress in meeting goals in the individualized treatment plan, and
• Evidence -that the beneficiary will benefit from additional units.
c. Intensive Outpatient Treatment
The CA may authorize up to 12 days in a twelve-month period based on
Medical Necessity Criteria, individualized determination of need, AAR
service requirements, and best practice standards.
The CA may authorize additional units based on these same criteria plus:
• The beneficiary's commitment to treatment based on participation
and attendance, and
• Progress in meeting goals in the individualized treatment plan, and
• Evidence that the beneficiary will benefit from additional units.
d. FDA Approved Pharmacological Supports for LAAM and Methadone
Page 16 of 21 September 2004
The CA may authorize up to ninety (90) days of Methadone treatment
based on medical necessity criteria, individualized determination of need,
AAR service requirements, best practice standards, and the criteria,
contained in this Agreement, for opioid dependent substance abuse
treatment with Methadone.
The CA may authorize additional treatment in increments of up to ninety
(90) days each based on these same criteria. In addition, the CA must
take into consideration each of the following factors when deciding
• whether to authorize additional 90-day increments:
• The beneficiary's commitment to treatment based on participation,
attendance, and results of urine screens; and
• Progress in meeting goals in the individualized treatment plan, and
• Evidence that the beneficiary will benefit from additional units.
• The CA may limit or discontinue the outpatient treatment
component at any time after the initial ninety (90) days of treatment,
based on evidence that outpatient treatment is not contributing
toward beneficiary progress in achieving objectives in the
individualized treatment plan. The CA may resume authorization of
outpatient treatment at any subsequent time, based on evidence
that such treatment will directly assist the beneficiary in achieving
objectives in the treatment plan.
36. Criteria for Authorizing and Reauthorizing Community-Grant-Funded FDA
Approved Pharmacological Supports for LAAM and Methadone
The CA may authorize up to ninety (90) days of Methadone treatment based on
the medical necessity criteria contained in the Agreement, individualized
determination of need, AAR service requirements, best practice standards, and
the criteria, contained in this Agreement, for opioid dependent substance abuse
treatment with Methadone.
The CA may authorize additional treatment in increments of up to ninety (90)
days each based on these same criteria. In addition, the CA must take
into consideration each of the following factors when deciding whether to
authorize additional 90-day increments:
• The beneficiary's commitment to treatment based on participation,
attendance, and results of urine screens;
• Progress in meeting goals in the individualized treatment plan;
• Evidence that the beneficiary will benefit from additional units; and
Page 17 of 21 September 2004
The CA may limit or discontinue the outpatient treatment component at
any time after the initial ninety (90) days of treatment, based on evidence
that outpatient treatment is not contributing toward beneficiary progress in
achieving objectives in the individualized treatment plan. The CA may
resume authorization of outpatient treatment at any subsequent time,
based on evidence that such treatment will directly assist the beneficiary
in achieving objectives in the treatment plan.
37. Methamphetamine Prevention Project
This provision is applicable only to those CAs that receive an earmarked
allocation for Methamphetamine Prevention Project funds.
The CA must establish a regional planning infrastructure that includes
stakeholder agencies involved in preventing methamphetamine use. The CA may
also use the allocated funds for methamphetamine-specific prevention
programming as identified through the local planning process with stakeholder
agencies. Stakeholder agencies include regional and local entities that provide
prevention, treatment and support services to consumers affected by
methamphetamine use and agencies charged with enforcing laws pertaining to
distribution, possession and production of methamphetamine.
The CA must allocate no less than 95 percent of the funding for infrastructure
development activity and methamphetamine-specific prevention programming.
Coordinating Agencies must not exceed a cap of 5 percent for administrative
costs associated with this grant activity.
The CA must enter its Methamphetamine Prevention Project revenues and
expenditures separately on the Revenue and Expenditures Report form.
Reporting requirements are as stated in Attachment C to this Agreement.
38. Tobacco Retailer Inspections
The CA must arrange for non-Synar inspections of tobacco retailers. Inspections
may be conducted using youth inspectors paired with law enforcement or civilian
teams. The CA may use allocated Prevention funds or resources outside this
agreement.
The number of inspections paid for through this Agreement shall not exceed 25
percent of the retailers on the Master List without written authorization from
ODCP The reimbursement rate per inspection shall not exceed $56.00 without
written authorization from ODCP.
SAPT Block Grant Funds cannot be used for law enforcement inspections.
ODCP assumes responsihility fnr monitoring compliance with this condition.
Page 18 of 21 September 2004
Inspections must be conducted using the FY 2004 formal Synar compliance
check protocol, including using the designated reporting form. These inspections
can be conducted throughout the fiscal year with the exception of the formal
Synar compliance check period of July 1 through July 31, 2005.
Required Reports: The CA is required to submit a monthly report on team
inspection activity, using a format supplied by ODCP titled Office of Drug Control
Policy/Prevention Section Non-Synar Monthly Compliance Check Report. These
reports are due the last day of the month following the reporting month.
39. Tobacco Vendor Education
The CA must conduct Tobacco Vendor Education visits in cooperation with the
Designated Youth Tobacco Use Representatives or in conjunction with the Local
Lead agencies, tobacco coalitions and law enforcement agencies. The CA must
provide on-site Tobacco Vendor Education sessions to at least 10 percerLt_eftb_e
tobacco retailers in the CA's region, using the ODCP-provided protocol. An
updated list of vendors will be distributed in a follow-up communication from the
ODCP Prevention Section.
On-site vendor education includes, but is not limited to: a) review of the Youth
Tobacco Act and the potential cost for selling to minors; b) tips for employee
training; c) provision of examples of store policy regarding tobacco sales that
vendors can use; d) provision of examples of directives to employees; e)
provision of examples of employee agreements; f) instructions on Youth Tobacco
Act signage and the placement of the signage; and g) provision of a tobacco
retailers guide.
The CA must also improve the accuracy of the list of tobacco vendors within the
CA region. This activity may be carried out in conjunction with the Designated
Youth Tobacco Use Representative or in conjunction with agencies listed above.
This activity includes: a) making_contact, visiti,:to each retailer
on their list to confirm whether that retailer sells tobacco .products; b) providing a
liSfof vendors identified and confirmed by' CA contact including address, phone
number, zip code, county and type of the vendor; c) identifying and providing a
list of confirmed vendors selling tobacco products over the counter or by vending
machines; and d) identifying and reporting additional retailers who sell tobacco
products, but do not appear on the retailer list.
Activity Timelines: The retailer list improvement activity must be completed by
March 31,2005.
Required Reports: A revised and improved retailer listing is due on March 31,
2005. The improved retailer listing shall include: a) confirmed tobacco retailers
listed by name, address, zip code, county and type; b) confirmed tobacco
retailers the sell over the counter or by vending machines; and c) additional
retailers that have been identified and confirmed as tobacco vendors The listing
Page 19 of 21 September 2004
must be sent to MDCH/Office of Drug Control Policy, Substance Abuse Contract
Management Section.
A report on the Tobacco Vendor Education activity is due July 31, 2005. The
report must include: a) a narrative description of the planning and implementation
of the activity including positive and negative experiences; b) number of vendors
visited; c) number of vendors receiving service; d) type of vendor; and e) level of
acceptance of vendor to information presented. The report must be sent to the
MDCH/Office of Drug Control Policy, Substance Abuse Contract Management
Section.
40. Medical Necessity Criteria For Substance Abuse Supports And Services
The CA must assure that treatment service authorization and reauthorization
decisions are consistent with the following Medical Necessity Criteria. These
criteria are substantively the same as the applicable criteria for substance abuse
Medicaid services.
1.0 Medical Necessity Criteria
1.1 "Medically necessary" substance; abuse services are supports,
services, and treatment:
1.1.1 Necessary for screening and assessing the presence of
substance use disorder; and/or
1.1.2 Required to identify and evaluate a substance use disorder;
and/or
1.1.3 Intended to treat, ameliorate, diminish or stabilize the
symptoms of a substance use disorder; and/or
1.1.4 Expected to arrest or delay the progression of a substance
use disorder; and/or
1.1.5 Designed to assist the individual to attain or maintain a
sufficient level of functioning in order to achieve his/her goals
of community inclusion and participation, independence,
recovery or productivity.
1.2 The determination of a medically necessary support, service or
treatment must be:
1.2.1 Based on information provided by the individual, individual's
family, and/or other individuals (e.g., friends, personal
assistants/aide) who know the individual; and
1.2.2 Based on clinical information from individual's primary care
physician or clinicians with relevant qualifications who have
evaluated the individual; and
1.2.3 Based on individualized treatment planning; and
1.2.4 Made by appropriately trained substance abuse
professionals with sufficient clinical experience; and
Page 20 of 21 September 2004
1.2.5 Made within federal and state standards for timeliness; and
1.2.6 Sufficient in amount, scope and duration of the service(s) to
reasonably achieve its/their purpose.
1.3 Supports, services and treatment authorized by the CA must be:
1.3.1 Delivered in accordance with federal and state standards for
timeliness in a location that is accessible to the individual;
and
1.3.2 Responsive to particular needs of multi-cultural populations
and furnished in a culturally relevant manner; and
1.3.3 Provided in the least restrictive, most integrated setting.
Residential or other segregated settings shall be used only
when less restrictive levels of treatment, service or support
have been, for that beneficiary, unsuccessful or cannot be
safely provided; and
1.3.4 Delivered consistent with, where they exist, available
research findings, health care practice guidelines and
standards of practice issued by professionally recognized
organizations or government agencies.
1.4 Using criteria for medical necessity, a CA may:
1.4.1 Deny services a) that are deemed ineffective for a given
condition based upon professionally and scientifically
recognized and accepted standards of care; b) that are
experimental or investigational in nature; or c) for which
there exists another appropriate, efficacious, less-restrictive
and cost-effective service, setting or support, that otherwise
satisfies the standards for medically-necessary services;
and/or
1.4.2 Employ various methods to determine amount, scope and
duration of services, including prior authorization for certain
services, concurrent utilization reviews, centralized
assessment and referral, gate-keeping arrangements,
protocols, and guidelines.
1.4.3 A CA may not deny services solely based on PRESET limits
of the cost, amount, scope, and duration of services; but
instead determination of the need for services shall be
conducted on an individualized basis. This does not
preclude the establishment of quantitative benefit limits that
are based on industry standards and consistent with 1.3.4
above, and that are provisional and subject to modification
based on individual clinical needs and clinical progress.
September 2004 Page 21 of 21
ATTACHMENT B
REVENUE AND EXPENDITURES REPORT
FORM/ INSTRUCTIONS
AND
EQUIPMENT INVENTORY SCHEDULE
Administration
Planned (2) YID/Final (3)
4. Methamphetamine
apefttagir4.1,;7,,,.
cr..4
Prevention
Planned (s) '(TO/Final (7)
1
, ?V'
so $0
0 $0
$0 $0 $0
$0 $0 $0
C. ABW
1. Current Year PEPM
2, Savings
C. Subtotal $01 $0
0 $01 $0 $0 $0 $01 $0
$01 $0 $01 $0 $0
Grand Total of Subtotals A-G $01 $0 $01 $0 $0 $0 $0
Cocgractor Name:
EXPENDITURE DETAIL
Funds Source (Column 1)
A. State Agreement
1. Community Grant
2. SDA
3. SIG
REVENUES AND EXPENDITURES REPORT FORM
Treatment
Planned (4) I '(TO/Final (5)
Exhibit A
Women's Specially
Planned (8) I '(TO/Final (9)
tt:
$0 $0 A. Subtotal
B. Medicaid
1. Current year PEPM
2. Reinvestment Savings
3. Earned Incentive Funds
B. Subtotal
D. MI Child
1. Current Year PEPM
2. Savings
D. Subtotal
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
E. Subtotal
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
Revenues/Expenditures Report Form (rev. 9/15/2004) Page 3 of 4
Corgractor Name:
EXPENDITURE DETAIL FIIV EIP/Training SIG 1 Methamphetamine
Planned (4) Planned (8) YTD/Final (7
REVENUES AND EXPENDITURES REPORT FORM Exhibit A
Planned (2) I YTD/Final (3) YTD/Final (5) I Planned (6) Funds Source (Column 1)
A. State Agreement
1. Community Grant 'HQ 2. SDA
3. SIG
4. Methamphetamine
,11,441
0 $0 $0
$0 $0 $0 $01 $0 $0
11-
$01 $0 $0 $0
$0 $01 $0
$0 $0 $0 $0 $01 $0
$0 $0 $0
Grand Total of Subtotals A-G
$01 $0
A. Subtotal
B. Medicaid
.1. Current year PEPM
2. Reinvestment Savings
3. Earned Incentive Funds
B. Subtotal
C. ABW
1. Current Year PEPM
2. Savings
C. Subtotal
D. MI Child
1. Current Year PERM
2. Savings
D. Subtotal
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
E. Subtotal
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
F 3venuestExpendiiures Report Form (rev. 9115/2004) Page 4 of 4
Exhibit A
Face Page
Revenues and Expenditures Report Form
Office of Drug Control Policy
Contractor Name Federal ID No. Date Prepared
A D
Budget Period Page Number(s)
Mailing Address (Number and Street) FROM: 1 of 4
B TO: E C
Contract Agreement (check one)
Contract No. (enter number)
H
City State ZIP Code 1:1 Original F Amendment No. (enter number) C C C I: Amendment I
Submission Type (check one):
j D Initial
0 April-June
0 October-December 0 January-March
0.July-September 5 Final ..
CERTIFICATION: I certify that I am authorized to sign on behalf of the local agency and that this is an accurate statement of expenditures and
collections for the report period. Appropriate documentation is available and will be maintained for the required period to support costs and receipts
reported.
Authorized Signature Date Title
K L M
Contact Person Telephone Number and E-mail Address
N 0
Revenues/Expenditures Report Form (rev. 9/15/2004) ,'age 1 of 4
Initial Annual Budget Plan (2)1 urrent Annual Budget Plan(31
Expenditures
Current Quarter (4} Funds Source (Column 1) R-evenues Balance (6) Year-to-Dale
tl
so
$0 $0
$0 $0 SO
$0
SO $0
$0 $0
-5= -44
so
$0
So
so
$0
$0
$0
$0
$0
$0
$0
SO
$0
SO
SO
SO
$0
SO
$0
$0
$0
$0
SO
$q
so
$o
$o
$0
So
so
So
so
$0
So
so
So
So
So
0
REVENUES AND EXPENDITURES REPORT FORM
Contractor Name:
Exhibit A
A. state Agreement
1. Community Grant
2. SDA
3. SIG
4 Methamphetamine
,
A. Subtotal
B. Medicaid
1. Current year PEPIVI
2. Reinvestment Savings
3. Earned Incentive Funds
B. Subtotal
C. ABW
1. Current Year PEPM
2. Savings
C. Subtotal
D. MI Child
1. Current Year PEPM
2. Savings
D. Subtotal
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
E. Subtotal
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
Grand Total of Subtotals A-G
Revenues/Expenditures Report Form (rev. 9/5512004) Page 2 of 4
Exhibit B
Face Page
Revenues and Expenditures Report Form
Office of Drug Control Policy
'Contractor Name Federal ID No. Date Prepared ,
38-5551234 / / ABC Substance Abuse Services, Inc. Budget Period Page Number(s)
Mailing Address (Number and Street) FROM: 10101104 1 of 4
320 S. Michigan Street TO: 09130105 Contract No. (enter number)
Contract Agreement (check one) 20052024
City State ZIP Code Amendment No. (enter number) 2 Originai
0 Any Town Am _40000 Amendment
0 Initial 0 October-December 0 January-March
Submission Type (check one):
0 April-June E July-September 0 Final
CERTIFICATION: I certify that I am authorized to sign on behalf of the local agency and that this is an accurate statement of expenditures and
collections for the report period. Appropriate documentation is available and will be maintained for the required period to support costs and receipts
reported.
Authorized Signature Date Title
Contact Person Telephone Number and E-mail Address
Revenues/Expenditures Report Form (rev. 9/15/2004) Page 1 of 4
Funds Source (Column 1) even ues
Initial Annual Budget Plan (2)1Current Annual Budget Plan(3 Year-to-Date (5) Balance (6)
Expenditures
Current Quarter (4)
$0
$0
$0
A. State Agreement
1. Community Grant
2. SDA
3. SIG
4. MethamOetamine
$2,549,962
$206,258
$140,085
$71,50
1016
$2,967,8051 $0
$0 $0
$0 $0
$0 $0
*Air
REVENUES AND EXPENDITURES REPORT FORM Exhibit B
[contract Name:
ABC Subitance Abuse Services, Inc.
$0
$2,067,805
A. Subtotal
B. Medicaid
1. Current year PEPM
2. Reinvestment Savings
3. Earned Incentive Funds
B. Subtotal
C. ABW
1. Current Year PEPM
2. Savings
C. Subtotal
D. MI Child
1. Current Year PEPM
2. Savings
D. Subtotal
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
E. Subtotal
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
Grand Total of Subtotals A-G
$01 $0
$0
$0
$0
$0
$0
$0
01 $0
0
$0
$01 $0
$0
$0
$0
$0
$0
$0
$01 $0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
—§1-01
$0
col
$0
$0
Revenues/Expenditures Reporl Form (rev. 9/1512004) Page 201 4
REVENUES AND EXPENDITURES REPORT FORM Exhibit B
EXPENDITURE DETAIL Prevention Women's Specialty Administration
Funds Source (Column 1) Planned (4) I YTD/Final (5) Planned (6) I YTD/Final (7) Planned (8) YTINFinal (9)
Treatment
A. State Agreement
1. Community Grant
2. SDA
3. SIG
$802,659 $147,000
4. Methamphetamine
'9WANOfillAffP,,Aid
$0 A. Subtotal $0 $0 $0 $0 $147,000 $802,659
B. Medicaid
1. Current year PERM
2. Reinvestment Savings
3. Earned Incentive Funds
B. Subtotal
C. ABW
1. Current Year PEPM
2. Savings
C. Subtotal 0 $01 SO $0 $0 $0
$0 $0 $0 $0 $0
$0 $0
Grand Total of Subtotals A-G $01 $0 $802,6591 $147,000 12)1
Contractor Name:
ABC Substance Abuse Services, inc.
D. MI Child
1. Current Year PEPM
2. Savings
0 D. Subtotal
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
E. Subtotal
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
$0
$0
$01 $0
$0
$0
Re /enues/Expenditures Report Form (rev. 9115(2004) Page S ot 4
Funds Source (Column 1)
A. State Agreement
Communitt Grant
2. SDA
3. SIG
Planned (2)
$100,200
$0 $0
SIG
Planned (4) YTD/Findl (.1) Planned (6) Y1 D/F inal (5) Y7D/Finar (7)
$0 $0 $0 $0 $0
01
Planned (8)
ler
Y.1 afrinal (9)
EXPENDITURE DETAIL HIV EIP/Training Methamphetarnine
4. Methamphetamine
$100,200 A. Subtotal
$0 $0 $0 $0 $0 $0
$0 $0 $0 $0 $0 $0 $0 $0
$0 $0 $0 $0 $0 $0 $0 $0
$0 $0 $0 $0 $0 $0 $0 $0
$0 $0 $0 $0 $0 $0
Grand Total of Subtotals A-G $100,200
REVENUES AND EXPENDITURES REPORT FORM
Contractor Name:
ABC Substance Abuse Services, Inc.
Exhibit B
B. Medicaid
1. Current year PEPM
2. Reinvestment Savings
3. Earned Incentive Funds
B. Subtotal
C. ABW
1. Current Year PEPM
2. Savings
C. Subtotal
D. MI Child
1. Current Year PEPM
2. Savings
D. Subtotal
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3 Other Local
E. Subtotal
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
Re wenues/Expendilures Report Form (rev. 9/15/2004) Page 4 ol 4
Exhibit C
Face Page
Revenues and Expenditures Report Form
Office of Drug Control Policy
Contractor Name Federal ID No. Date Prepared
malm..-- I
Budget Period Page Number(s)
Mailing Address (Number and Street) FROM: 1 of 4
TO: Contract No. (enter number)
Contract Agreement (check one)
City State ZIP Code 3 Original Amendment No. (enter number)
r.... Amendment
O Initial 0 October-December 0 January-March Submission Type (check one):
0 April-June 0 July-September 0 Final
CERTIFICATION: I certify that I am authorized to sign on behalf of the local agency and that this is an accurate statement of expenditures and
collections for the report period. Appropriate documentation is available and will be maintained for the requ
Authorized Signature Date Title
Contact Person Telephone Number and E-mail Address
ir
Revenues/Expenditures Report Form (rev. 9/1512004) Page 1 of 4
REVENUES AND EXPENDITURES REPORT FORM Exhibit C
-
$0 1 $0
,
A. Subtotal 0
$0
$0
$0 $0 $0
B. Medicaid
1. Currel it year PEPM
2. Reilive:Ament Savings
3. Earned Incentive Funds
B. Subtotal
$0
$0
$0
$01 $0
C. ABW
1. Curler. Year PEPM $01 $0
0 $0 $0
2. Savings
C. Subtotal
$01 $0
$01 $0
$0 $0
$0
$0
$0
D. MI Child
1. Current Year PEPM
2. Savings
D. Subtota
$0
$0
$01 $0
$0 $0
$0
$0
$0
$0
$0 Of $0 E. Subtotal
0 $0
$0
$0 k3_11 1,(11 Grand Total of Subtotals A-G Of $0
Contractor Name:
Funds Source (Column 1) R-e-venues
Initial Annual Budget Plan (2)[Current Annual Budget Plan(3
Expenditufei
Current Quarter (4) 1 Year-to-Date (51 Balance (6)
A. State Agreement
1. Community Grant
2. SDA
3. SJG
4. Methamphetamine
$0
$0
$0
$0
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
Re.enues/Expenditures Report Form (rev. 9(15/2004) Page 2 of 4
Contractor Name:
EXPENDITURE DETAIL I Administration Prevention VVomen's Specialty
Funds Source (Column 1)
A. State Agreement
1. Community Grant
2. SDA
3. SIG
4. Melhamphetamine
FANkfloyiDrif
Planned (2) I YTD/Final (3) Planned (6) I YrD/Final (7) Planned (8)
Nt>lietYg'$:
A. Subtotal
B. Medicaid
1. Current year PERM
2. Reinvestment Savings
3, Earned Incentive Funds
B. Subtotal
C. ABW
1. Current Year PEPM
2. Savings
C. Subtotal
D. MI Child
1. Current Year PEPM
2. Savings
2. PA2 Fund Balance
3. Other Local
E. Subtotal
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
Grand Total of Subtotals A-G
REVENUES AND EXPENDITURES REPORT FORM Exhibit C
Revenues/Expenditures Report Form (rev. 9/15/2004) Page 3 of 4
YTafinal (3) Planned (4) i YTD/Final (5) I Planned (6) `CIT)1i-inal (7) I Planned (8) YTD/Final (9)
$0
$0
$0 $01 $0 $01 $0
$0 $0
$0 $0 $0 $01 $0
0 $0 $0 $0
so $01 so
Grand Total of Subtotals A-G
$01 $01 $01 $0 $01 $0 $0 $0
Contractor Name:
EXPENDITURE DETAIL
REVENUES AND EXPENDETURES REPORT FORM
HIV ElRI-raining SIG Methamphetamine I Other
Exhibit C
Funds Source (Column 1) I Planned (2)
A. State Agreement
1. Community Grant
2. SDA
3. SIG
4. Metharnphetamine
IA. Subtotal
B. Medicaid
1. Current year PEPM
2. Reinvestment Savings
3. Earned Incentive Funds
B. Subtotal I $0
C. ABW
1. Current Year PEPM
2. Savings
C. Subtotal
D MI Child
1. Current Year PEPM
2. Savings
D. Subtotal
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
,3. Other Local
E. Subtotal
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
Resanues/Expenditures Report Form (rev. 9/15/2004) Page 4 o14
Attachment B
Revenue and Expenditures Report Form Completion Instructions
Office of Drug Control Policy
Michigan Department of Community Health
Fiscal Year 2004105
I. INTRODUCTION:
The main purposes and applications of this Revenue and Expenditures Report (RER)
form include the following:
• Display revenue sources and expected amounts, and how these are budgeted at
the start of a fiscal year;
• Enable management and monitoring of federal and state spending requirements;
and
• Enable reconciliation of prepayments and expenditures on a quarterly and
annual basis.
The RER form is part of the Office of Drug Control Policy (ODCP)/CA and
ODCP/direct contractor contracts. With the exception of a single Program
Budget Summary Composite sheet, it replaces the Program Budget Summary
and Cost Detail forms and Financial Status Reports (DCH-0385/0386 and DCH
0384, respectively). This RER form is available in Microsoft Excel and will be
provided by MDCH/ODCP. The "Subtotal", "Grand Total of Subtotals A -G",
and "Year -to -Date" cells contain formulas that will calculate automatically.
Agencies must use the forms provided. Alternate forms or software may not be
used.
The RER form is used to provide- a standardized format for reporting the financial
status of individual programs. Al! expenditures and revenues (including
Medicaid, Adult Benefits Waiver [ABM, Ml Child. Local, Fees and Collections,
and Other Contracts and Sources) for the particular program are reported on the
RER form.
Requirements Regarding Administrative Budgets and Expenditures--
Agency budgets and expenditures for Administration must be reasonable,
prudent, and commensurate with meeting the requirements of this Agreement,
consistent with OMB Circular A-87 or A-122, as applicable.
If the Administration budget for a contractor that is a local government entity
contains a central cost allocation amount or rate, this allocation must have been
developed consistent with OMB Circular A-87, Attachment C. Payments are
subject to recovery, based on audit findings. Contractors that are non-profit
entities cannot have central cost allocations under this Agreement.
When there is a central cost allocation, the CA must also submit, on CA
letterhead, a Central Cost Allocation Plan Certification (below) whenever a
central cost allocation is introduced or is revised, or every two years, whichever
is sooner. This Central Cost Allocation Plan Certification form is available
eleolionically (in WORD) from the ODCP contract manager.
Revenue and Expenditures Report Form Instructions (Sept. 2004) (Word) Page 1 of 8
Attachment B
(Printed On Agency Letterhead)
Central Cost Allocation Plan Certification
This Central Cost Allocation Plan Certification form should be used for certification of
the agency's Central Cost Allocation Plan. This form must be signed by the Executive
Director or Finance Director of the agency.
The Central Cost Allocation Plan was developed
(Agency Name)
consistent with OMB Circular A-87 cost principles. (A-87 can be found at:
http://wvvw.whitehouse.00v/omb/circulars/a087/a87 2004.html)
Please check one of the following and sign below:
I certify that the Central Cost Allocation Plan has been reviewed by our external
auditor and has been found to be consistent with OMB Circular A-87 principles.
Or
I certify that our external auditor will review the Central Cost Allocation Plan for
consistency with OMB Circular A-87 principles, at the next audit.
Name (print) Title
Signature Date
Revenue and Expenditures Report Form Instructions (Sept. 2004) (VVord) Page 2 of 8
Attachment B
Initial annual budgets (expected revenue) are incorporated into agency contracts.
Quarterly expenditure reports must be submitted to the Michigan Department of
Community Health (MDCH)/Accounting not later than the last day of the month
following the end of the quarter. Final annual expenditure reports will be due by
December 15 following the end of the fiscal year. A copy of each quarterly and
final report must be e-mailed to the address given below under II. Distribution.
Expenditure targets for selected program areas, such as Women's Specialty
Services, will also be provided by MDCH/ODCP at the beginning of the fiscal
year in the agency's allocation letter. Revised allocations and expenditure
targets will be issued, as needed.
Reporting of revenues and expenditures must be consistent with Generally
Accepted Accounting Principles (GAAP).
IL DISTRIBUTION:
The original and two (2) copies of the RER form should be prepared and
distributed as follows:
Original - Michigan Department of Community Health
Bureau of Finance/Accounting Division
Expenditure Operations Section
P.O. Box 30720
Lansing, Ml 48909-8220
One Copy - Retained by agency.
One Copy - Submitted electronically to:
Michigan Department of Community Health
Office of Drug Control Policy
Denise Murray
E-mail: murrayden(C4michioan.00v
III. RETENTION:
This report should be retained for a period complying with the retention policies
established in the Agreement.
IV. FORM PREPARATION:
An RER form instruction example (Exhibit A), an RER form completed example
(Exhibit B), and an RER form blank example (Exhibit C) are attached for
reference.
Revenue and Fxpenditores Report Form Instructions (Sept. 2004) (VVord) Page 3 of 8
Attachment B
Revenue and Expenditures Report Form/Face Paae—Paoe
A. Contractor Name – Enter the name of the agency.
B. Mailing Address – Enter the street address of the agency.
C. City, State, ZIP Code – Enter the City, State, and ZIP Code of the
agency.
D. Federal ID No. – Enter the Federal Employer Identification Number
E. Budget Period – Enter the inclusive dates covered by the RER form.
F. Contract Agreement Check either "ORGINAL" or "AMENDMENT".
G. Date Prepared – Enter the date on which the RER form is prepared.
H. Contract No. – Enter the MDCH Contract Number.
I. Amendment No. – Enter the Amendment Number of the MDCH Contract
Number.
J. Submission Type – Check one of the six (6) boxes, identifying the period
covered by the RER form.
Certification Section:
This Certification Section must be signed by an authorized official certifying that
documentation and records are available and easily accessible in support of all
the data contained on the report. The individual signing on behalf of the agency
certifies by his/her signature that he/she is authorized to sign on behalf of the
agency. Any item found as a result of audits to be improper or undocumented
will be subject to an audit citation and generally will require a payment
adjustment.
K. Authorized Signature – Enter the signature of the official authorized to
sign the RER form.
L. pate – Enter the date of the authorized signature.
M. Title – Enter the title of the official authorized to sign the RER form.
N. Contact Person – Enter the name of the person to whom questions
should be directed concerning the RER form.
O. Telephone Number and E -mail Address Enter the telephone number
and e-mail address of the Contact Person.
Revenue and Expenditures Report Form—Page 2
A. Contractor Name – Enter the name the agency.
Revenues (Columns 2 and 3)
B. Initial Annual Budget Plan—Column 2
For each row in Section A, enter the amount of each fund source, as
listed in the agency's allocation letter. For most agencies, these fund
sources will include Community Grant, State Disability Assistance (SDA),
State Incentive Grant (SIG) and other fund sources, as appropriate.
These allocations will be provided by MDCH/ODCP at the beginning of the
fiscal year in the agency's allocation letter and during the fiscal year, as
needed to reflect amendments.
Revenue and Fxpenditures Report Form Instructirms (Sept, 2004) (Word) Page 4 of 8
Attachment B
For each row in Sections B through G, enter the amount of each fund
source that the agency expects to receive during the fiscal year. These
may include: Medicaid, Adult Benefits Waiver, MI Child, Local, Fees and
Collections, and Other Contracts and Sources.
C. Current Annual Budget Plan —Column 3
All amount changes in any fund source categories as posted for Section A
only in the Initial Annual Budget Plan –Column 2 require a contract
amendment. This Current Annual Budget Plan–Column 3 will remain
blank unless or until an amendment is needed.
For fund sources in Sections B through G, changes in expected
revenues must be entered in Column 3 and reported on quarterly and
final expenditure reports. Contract amendments are not needed for
Sections B through G. Budget and expenditure requirements for Local
Match remain in effect.
Expenditures (Columns 4-5)
D. Current Quarter—Column 4
For each row in Sections A through G, enter the current quarter
expenditures for each fund source in Column 1.
E. Year-to-Date—Column 5
For each row in Sections A through G, enter the year-to-date
expenditures for each fund source in Column 1. Each amount will be the
cumulative total expenditure amount for each budget title listed on Pages
3 and 4, under each "YID/Final" column heading.
Balance (Column 6)
F. Balance
For each row in Sections A through G, enter the balance obtained by
subtracting the amount in the Year-to-Date (Column 5) from the amount in
the Current Annual Budget Plan (Column 3). If there is no amount in
Current Annual Budget Plan (Column 3), then enter the balance obtained
by subtracting the amount in the Year-to-Date (Column 5) from the
amount in the Initial Annual Budget Plan (Column 2).
Revenue and Expenditures Report Form —Page 3
Selected program area titles are pre-entered in the column headings on Pages 3
and 4. Other areas may need to be added. There will be some variation in these
across agencies.
G. Contractor Name – Enter the name the agency.
Revenue and Expenditures Report Form Instructions (Sept. 2004) (Word) Page 5 of 8
Attachment B
Expenditure Detail--Planned (Columns 2 (H), 4 (J), 6 (L), and 8(N))
For each row in Section A, enter the planned (budgeted) expenditures for each
fund source (Column 1) for the current report period. These expenditures are for
Administration, Treatment, Prevention and Women's Specialty. Other program
expenditure areas are listed on Page 4. These planned expenditures must be
the same as any specific allocations or spending targets stated in the ODCP
allocation letters, unless revisions are approved in writing in advance by the
ODCP Bureau Director.
For each row in Sections B through G, enter the planned (budgeted)
expenditures of each fund source (Column 1) for the current report period.
Expenditure Detail—YTD/Final (Columns 3 (I), 5 (K), 7 (M), and 9 (0))
For each row in Sections A through G, enter the year-to-date expenditures for
each fund source (Column 1). These expenditures are for Administration,
Treatment, Prevention and Women's Specialty.
Revenue and Expenditures Report Form—Page
P. Contractor Name – Enter the name the agency.
Expenditure Detail--Planned (Columns 2 (0), 4 (S), 6 (U) and 8 (W))
For each row in Section A, enter the planned (budgeted) expenditures for each
fund source (Column 1) for the current report period. These expenditures are for
HIV EIP/Training, SIG, Methamphetamine and Other. These planned
expenditures must be the same as any specific allocations or spending target
stated in the ODCP allocation letters, unless revisions are approved in writing in
advance by the ODCP Bureau Director.
For each row in Sections B through G, enter the planned (budgeted)
expenditures of each fund source (Column 1) for the current report period.
Expenditure Detail—YTD/Final (Columns 3 (R), 5 (T). 7 (V) and 9 (X))
For each row in Sections A through G, enter the year-to-date expenditures for
each fund source (Column 1). These expenditures are for HIV EIP/Training, SIG,
Methamphetamine and Other.
For all rows, expenditures reported on Pages 3 and 4 must equal expenditures
reported in Column 5, Page 2.
Due Dates for Amendments and Revisions
Requests for budget amendments must be submitted in writing to the ODCP
contract manager not later than the due date for final amendments to this
Agreement. This date is typically in late June annually. ODOR will notify the
contractor of a specific date at least 30 days in advance of the due date.
Revenue and Fxpenditures Report Form Instructions (Sept. 2004) (Word) Page 6 of 8
Attachment B
Revisions in planned expenditures of Section A funds must be approved in
advance, in writing by the ODCP Bureau Director. Revisions musty be
incorporated into subsequent quarterly expenditure reports. The final annual due
date to request revisions is twenty days after the end of the Agreement period,
that is, October 20 for annual Agreements.
Revisions in planned revenues and expenditures of funds in Section B-G must be
reported on quarterly expenditure reports as revisions are identified, and not later
than the final annual report, subject to applicable requirements in this Agreement.
Program Budget Summary Composite
Attachment B.1 is a Program Budget Summary form (DCH-0385E, revised 4-04).
The department's contract manager will complete this form and include it in the
executed Agreement to be returned to the contractor. In addition to the
identifying information at the top of the form, there will be three entries:
1. Line 7, Other Expenses, will show the sum of the State Agreement
Subtotal in column 2 on page 2 of the RER and the local match amount
selected by the contractor. This is the same "total amount of agreement"
that is entered in the top line of Part I, Section 2.A on page 1 of this
agreement.
2. Line 12, State Agreement, will show the Subtotal for Section A, State
Agreement, column 2, from page 2 of the RER.
3. Line 15, Other, will show the local match amount (not all local funds, just
the amount selected as the match amount.
Amendments to the Program Budget Summary form are required when there are
changes in the State Agreement fund sources or amounts.
Cvn-,-1,r4;4.111-nc nrr.1-1 I nctri le•finnc 7nne.) flAfr-v-rin Pang+. 7 nf R
Attachment B
Revenue and Expenditures Report Form
FINAL REPORTING
Fiscal Year 2004/05
The RER form for the last quarter of the Agreement period (or other prescribed
reporting period) is to be prepared the same as previous quarterly reports and is due no
later then thirty (30) days from the end of the Agreement period. This report is
considered a preliminary final RER form.
A final RER form is due by December 15; that is, by seventy-six (76) days after the end
of the Agreement period. The form must be marked "FINAL" on the Face Page. This
requires the agency to liquidate all accounts payable and encumbrances by December
15. (See definitions below).
Exceptions may be granted for one-time obligations that cannot be liquidated within this
time period. However, should this be the case, an additional fifteen (15) days may be
provided if a written request for an extension, with the reason why additional time is
needed, is submitted by the due date of the final RER form. Please submit such
requests to the same address as quarterly reports are mailed.
Failure to meet these final reporting deadlines may result in the State's inability to
reimburse the full amount of the state's share of the gross expenditures.
In addition to submitting RERs, other financial information will be requested to assist
MDCH in properly closing the State's fiscal year (September 30). This information will
help ensure sufficient funds have been reserved by the state to make reimbursement for
the contract in the State's upcoming fiscal year. The additional financial information
required will include an estimate of open commitments and obligations incurred as of
September 30, but not yet paid. The MDCH/Accounting Division will provide detailed
instructions for reporting additional financial information mid-August of each year.
DEFINITIONS:
• Accounts Payable - Obligations for goods or services received, which have not
been paid for as of the end of the Agreement period.
• Encumbrances - Commitments at the end of the Agreement period related to
unperformed (executory) contracts for goods and services.
Note: If a contract does not end on September 30, it is still necessary to estimate
accounts payable as of September 30.
All inquiries regarding financial reporting issues should be directed to the Expenditure
Operations Section of the MDCH/Accounting Division.
References:
ir Michigan Department of Management and Budget
• Guide to State Government (1210.27).
• Year-End Closing Guide.
Fedora! OMB Circular A-102 (Rovised & DHHO Common Rule).
Revenue and Expenditures Report Form instructions (Sept. 2004) (Word) Page 8 of 8
ATTACHMENT B.1
PROGRAM BUDGET SUMMARY
MICHIGAN DEPARTMENT OF COMMUN:TY HEALTH
Program Date Prepared Page Cf
Contractor Name BUDGET PERIOD
From: To: _ Mailing Address (Number and -Street) Agreement: Amendment Number
Original EAmendment n
City State ZIP Code Fp,deral ID .Nymber
TOTAL EXPENDITURE CATEGORY __BUDGET
. Salaries and Wages
2. Fringe Benefits
3. Travel
4. Supplies and Materials
5. Contractual (Subcontracts)
6. Equipment
7. Other Expenses:
8. Total Direct Expenditures -
(Sum of Lines 1-7)
9. Indirect Costs: Rate #1 %
Indirect Costs: Rate #2 %.
10. TOTAL EXPENDITURES
SOURCE OF FUNDS:
11. Fees and Collections
12. State Agreement
13. Local
14. Federal
15. Other(s):
16. TOTAL FUNDING
4'
AUTHORITY: P.A. 368 of 1978
COMPLETION: Is Voluntary, but is required as a
condition of funding
The Department of Community Health is an equal opportunity
F: mpinyer siarvinas and prnarams prnviriiar
DCH-0385(E) (Rev 3-04) (1N) Previous Edition Obsolete. Also Replaces FIN-110
ATTACHMENT B.2
MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
CONTRACT MANAGEMENT SECTION
EQUIPMENT INVENTORY SCHEDULE
Please list equipment items that were purchased during the grant agreement period as
specified in the grant agreement budget, Attachment B.2. Provide as much information
about each piece as possible, including quantity, item name, item specifications: make,
model, etc. Equipment is defined to be a article of non-expendable tangible personal
property having a useful life of more than one (1) year and an acquisition cost of $5,000
or more per unit. Please forward to this agreement's contract manager.
Contractor Name: Contract #: Date:
0 uantity Item Name Item Specification Tag Number Budgeted
- Amount
$
,
p - . 1 ,
.., ..
$
$
S
$
Total $ 0
Contractor's Signature: Date:
ATTACHMENT C
REQUIRED REPORTS
ATTACHMENT C
REQUIRED REPORTS—Fiscal Year (FY) 2005
The following table indicates the reports that the Contractor is required to submit to the
Department under this agreement. The table also indicates the time period covered by
each report, the report due date, where within the Department the report must be
submitted, and the location or source of instructions and specifications for completing
the report.
The contents of the table supersede any other communication of reporting
requirements, including requirements stated in the Annual Action Plan Guidelines
(AAPG). Amendments to the "Required Reports" table show changes in "BOLD".
Contractors are responsible for submitting all reports on time and per instructions.
Reports transmitted on or before the due date are considered timely. Transmission
date is determined by postmark, commercial carrier receipt, date of fax or date of
electronic transmission. Reports that do not conform to instructions may not be
determined as "received."
Page 1 of 5 (September 2004)
Attachment C
Required Reports—Fiscal Year (FY) 2005
Document Title Period Due Date Instructions &
Covered Specifications .
Adult Benefits Waiver Financial Fiscal Year October 31, 2004 (SACM) FY 2004 Contract,
Report 2004 as amended
Fiscal Year Per Quarterly and Final Contract
2005 Expenditures Report j Attachment B
Audit Report Fiscal Year 9 months after close of Contract, Part II
Contractor's fiscal year
(Office of Audit)
Communicable Diseases (CA Semi-Annual April 30 and October 31 Per August 18, 2004
TB, Hepatitis, STD Services Plan (SACM) e-mail with
and HIV EIP Plan) attachment.
Expenditures Report--Final Fiscal Year December 15, 2004 Contract
2004 (BFA/Acccunting) Attachment B
Fiscal Year December 15, 2005 Contract
2005 (BFA/Accounting) Attachment B
Expenditures Report--Quarterly Quarterly (Oct- Last day of the month, Contract
Nov; Jan- following the end of the Attachment B
March; April- quarter: January 31, April
June; July- 30, July 31, and October
Sept.) 31. (BFA/Accounting)
Health Insurance_Portability & As services Last day of following month, Supplemental
Accountabilit Act (HIPAA) 837 are provided, submitted via DEG to Instructions for
Encounters records are MDCH/MIS-Operations Quality Improvement
completed. (Q1) Data
Submissions Submission for
are all monthly Substance Abuse
records for Coordinating
each quarter. Agencies (10/04)
Injecting Drug Users 90% Monthly Last day of the month FY 2004 AAPG
Capacity Treatment Report and following the report month.
Federal Priority Populations Submit via U.S. mail
Waiting List Certification Report (SACM).
Methamphetamine Grant Quarterly or Fiscal Year 2004: Per July 27, 2004 e-
Narrative Report semi-annually October 15, 2004 mail to CAs with
NOTE: Applies only to according to attached grid; format
Fiscal Year 2005:
-
agencies with allocations for project year. as distributed at Aphl
this program. January 15, 2005 29, 2004 grantee
March 15, 2005 meeting.
October 15, 2005
f
Page 2 of 5 (September 2004)
Attachment G
Required Reports—Fiscal Year (FY) 2005
Document Title Period Due Date Instructions &
Covered ig ii_fi o
MIChild Financial Report Fiscal Year October 31, 2004 Contract
2004 Attachment A
Fiscal Year Per Quarterly and Final Contract
2005 Expenditures Report Attachment B
Non-Synar Tobacco Retailers Monthly Last day of the month Prevention Section
Inspections Report following the report month, will e-mail
instructions to CAs
with instructions and
form.
Notice of Excess or Insufficient Fiscal Year May 1 (SACM) Contract
Funds Attachment A
Payables Report Fiscal Year October 2005 Contract
(BFA/Accounting) Attachment B
Determined by DMB at
year-end closing
Performance Indicators Quarterly (Oct- Last day of the month, Electronic
Nov; Jan- following the end of the Submission Forms:
March; April- quarter: January 31, April Performance
June; July- 30, July 31, and October - Indicators for
Sept.) 31. (SACM) Substance Abuse
Services (Revised
12/02)
Indicators
I **DISCONTINUED IN FISCAL
YEAR 2005**
Prevention Expenditures Report Fiscal Year January 31—for prior fiscal FY 2002 AAPG,
year (SACM) Revision, dated
06/28/01
2. - - - es. -e- e.— - -e Quarterly (Oct Last day of the month, FY 2001 AAPG
Report Nov; Jan i.
-"DISCONTINUED IN FISCAL March; April quarter: January 31, April
YEAR 2005** June; July
Sept.) al. (PreveRtie-R)
Prevention Services Population I Semi-Annual April 30 and October 31 FY 2004 AAPG
Report (SACM)
•
Page 3 of 5 (September 2004)
Attachment C
Required Reports—Fiscal Year (FY) 2005
Document Title Period Due Date Instructions &
Covered Specifications . . Sentinel Events Data Summary Semi-Annual Last day of the month CA letter dated
(residential treatment only) CA Summary following the end of the 2'1 October 3, 2001
& 4th quarters: April 30 and
October 31 (SACM)
Substance Abuse Entity Fiscal Year January 31—for prior fiscal Instructions will be
Inventory/Legislative Report year (SACM) issued by December
10 annually.
Tobacco Narrative Report Semi-annual April 30 and October 31 FY 2004 AAPG
(SACM)
Tobacco Retailer Listing-- , Annual March 31 (SACM) Contract
Improved Attachment A
Tobacco Vendor Education Annual July 31 (SACM) Contract
Activity Report Attachment A
Treatment admission and • Submissions Last day of each month, Supplemental
treatment discharge records data are records for submitted via DEG to Instructions for
upload (QI) each month MDCH/MIS-Operations Quality Improvement
(QI) Data
, Submission for **SARF NO LONGER Substance Abuse REQUIRED – per August 19, Coordinating 2004 email to CAs," Agencies (10/04)
Women & Families Progress Semi-Annual April 30 and October 31 Per August 24, 2004
Narrative Report and Annual, (SACM) e-mail with
respectively attachment.
Bureau of Finance/Accounting (BFA/ACCOUNTING) reports should be sent to:
Michigan Department of Community Health
Bureau of Finance/Accounting Division
Expenditure Operations Section
P.O. Box 30720
Lansing, Michigan 48909
Client Admission and Discharge Client records must be sent electronically to:
Michigan Department of Community Health
Michigan Department of Information Technology
Data Exchange Gateway (DEG)
For admissions: put c:14823 4823(dchbull
For discharges: put o:\4824 4824CcD,dchbull
Page 4 ot 5 (September 2004)
Attachment C
Required Reports—Fiscal Year (FY) 2005
Office of Audit reports should be sent to:
Michigan Department of Community Health
Office of Audit
Quality Assurance and Review Section
P.O. Box 30479
Lansing, MI 48909-7979
Substance Abuse Contract Management Section (SACM) reports should be sent to:
Michigan Department of Community Health
Office of Drug Control Policy
Substance Abuse Contract Management Section
Lewis Cass Building, 5th Floor
320 S. Walnut Street
Lansing, Michigan 48913
Page 5 of 5 (September 2004)
FY2005
Adopted
$4,702,614
FY2005
Adjustment
($47,698)
FY2005
Amended
Budget
$4,654,916
Revenue
1-275497-72500-0171 State
FISCAL NOTE (MISC. #04319) November 18, 2004
BY: FINANCE COMMITTEE, CHUCK MOSS, CHAIRPERSON
IN RE: DEPARTMENT OF HUMAN SERVICES/HEALTH DIVISION - 2004/2005 SUBSTANCE ABUSE
GRANT ACCEPTANCE
TO THE OAKLAND COUNTY BOARD OF COMMISSIONERS
Chairperson, Ladies and Gentlemen:
Pursuant to Rule XII-C of this Board, the Finance Committee has reviewed
the above-referenced resolution and finds:
1. The Department of Human Services/Health Division has been awarded by
the Michigan Department of Community Health (MDCH) $4,654,916 in
Substance Abuse Grant funds.
2. Funds will be used to subcontract with agencies to prevent and
reduce the incidence of drug and alcohol abuse and dependency.
3. The County is expected to incur $66,294 in support costs, which have
been included in the FY2005 budget.
4. Grant acceptance represents a decrease from the prior year grant
amount of ($47,698) a (1%) decrease from the previous year.
5. The grant period extends from October 1, 2004 through
September 30, 2005.
6. The Fiscal Year 2005 budget should be amended to match the Fiscal
Year 2004 award as delineated below.
Expense
2-354997-72500-2572 Contracted Svs.
2-654997-54310-2572 Contracted Svs.
2-654997-54310-2572 Contracted Sys.
2-554997-54330-2572 Contracted Svs. 70,000
2-754997-72500-2572 Contracted Sys. 4,070,940
$4,702,614
271,674
(47,698) 242,302
70,000 70,000
(70,000)
4,070,940
(47,698) $4,654,916
271,674
290,000
FINANCE COMMITTEE
FINANCE COMMITTEE
Motion carried unanimously on a roll call vote.
,or
Resolution #04319 November 18, 2004
Moved by Wilson supported by Hatchett the resolutions on the Consent Agenda be adopted (with
accompanying reports being accepted).
AYES: Coleman, Crawford, Douglas, Gregory, Hatchett, Jarnian, Knollenberg, KowaII, Law, Long,
McMillin, Middleton, Moffitt, Moss, Palmer, Patterson, Potter, Rogers, Scott, Suarez, Webster, Wilson,
Zack, Bullard. (24)
NAYS: None. (0)
A sufficient majority having voted therefore, the resolutions on the Consent Agenda were adopted (with
accompanying reports being accepted).
"M.
STATE OF MICHIGAN)
COUNTY OF OAKLAND)
I, G. William Caddell, Clerk of the County of Oakland, do hereby certify that the foregoing resolution is a true
and accurate copy of a resolution adopted by the Oakland County Board of Commissioners on
November 18th, 2004 with the original record thereof now remaining in my office.
In Testimony Whereof, I have hereunto set my hand and affixed the sj* ofty County of 5..)Tkland at
Pontiac, Michigan this 18th day of November, 2004.
G. William Caddell, County Clerk