HomeMy WebLinkAboutResolutions - 2005.11.10 - 27953MISCELLANEOUS RESOLUTION #05265 November 10, 2005
BY: General Government Committee, William R. Patterson, Chairperson
IN RE: DEPARTMENT OF HEALTH AND HUMAN SERVICES/HEALTH DIVISION — 2005/2006
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) $4,640,745 in Substance Abuse Grant Funds for the period
of October 1, 2005 through September 30, 2006; and
WHEREAS the 2005/2006 grant award includes $4,640,745 in grant revenue and
expenditures for this program, a decrease of $14,171 (.03%) 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 2005/2006 Substance Abuse Grant from the Michigan Department of
Community Health in the amount of $4,640,745,
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
General Government Committee Vote:
Motion carried on a roll call vote with Long, Hatchett and Molnar absent.
Tom Fackler
From: Greg Givens rgivensg@co.oakland.mi.us)
, Sent: Friday, October 21, 2005 10:01 AM
To: Doyle, Larry; Fockler, Tom; Pearson, Linda
Cc: Frederick, Candace; Smith, Laverne; Mitchell, Sheryl; Pardee, Mary; Hanger, Helen; Wenzel,
Nancy; Johnston, Brenthy; Worthington, Pam; Ross, John
GRANT REVIEW — Health Division / Substance Abuse
GRANT REVIEW - Health Division
GRANT NAME: FY 2006 Local Health Department Substance Abuse Agreement FUNDING
AGENCY: Michigan Department of Community Health DEPARTMENT CONTACT PERSON:
Tom Fockler 2-2151
STATUS: Acceptance
DATE: October 21, 2005
Pursuant to Misc. Resolution #01320, please be advised the captioned grant materials
have completed internal grant review. Below are the comments returned by review
departments.
Please note the comment from Corporation Counsel. This issue needs to be revolved
before submission to the Board for acceptance.
Noting the above comment, 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 (10/13/2005)
Department of Human Resources:
Approved. - Nancy Scarlet (10/18/2005)
Risk Management and Safety:
Approved By Risk Management - Julie Secontine (10/17/2005)
Corporation Counsel:
I have reviewed this Agreement and the Addendum A and approve the same for signing
with one note. In item #3 of Addendum Af I have requested Tom Fockler change
"Scope" to "Standard." He has agreed to do so and will submit the revised Addendum A
to you for attachment to the Agreement that will be signed. - John Ross (10/17/2005)
Subject:
1
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 1.11#: 38-6004876
hereinafter referred to as the "Contractor" or the "Coordinating Agency"
for
Substance Abuse Services
Part I
1. Period of Agreement: This agreement shall commence on October 1, 2005 and
continue through September 30, 2006. 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 $ 9,343,208. The Department under the
terms of this agreement will provide funding not to exceed $ 4,640,745. The
federal funding provided by the Department is $ 3,168,642 , as follows:
Federal Program Catalog of Federal CFDA # Federal Federal Grant Amount
Title Domestic Agency Name Award
Assistance (CFDA) Number
Title
SAPT Block Grant Block Grant for 93.959 Department of 00 B1 MI $3,168,642
Prevention and Health and SAPT 06
Treatment of Human
Substance Abuse Services
Total FY 2006 Federal Funding $3,168,642
DCH-0665FY2006 2/05 (W) 1 of 16
The grant agreement is designated as a:
subrecipient relationship; or
n vendor relationship.
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.
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.
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.
5. Financial Requirements: The financial requirements 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. The Contractor
also agrees to comply with the requirements described in Attachment F—Other
Requirements, which is part of this agreement through reference.
(tern 2.B is
not
applicable
Item 2.0
is not
applicable
DCH-0665FY2006 2/05 (W) 2 of 16
Name (Please print) Title
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, Substance Abuse Contract Mgmt.; 517.335.0180i
SteinbergMmichigan.gov
Name, Location/Building Title Telephone No. Email Address
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
Kosiksco.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.
It 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 Date
For the MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
Nick Lyon, Deputy Director, Operations Administration Date
DCH-0665FY2006 2/05 (W) 3 of 16
Part ll
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. Any
underrecoveries of otherwise available fees resulting from failure to bill for
eligible services will be excluded from reimbursable expenditures.
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 date 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 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.
DCH-0665FY2006 2/05 (W) Part I (REVISED 09123/05) 4 of 16
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
This section only applies to Contractors designated as subrecipients.
Contractors designated as vendors are exempt from the provisions of this
section.
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," (as revised) a copy of the
Contractor's annual Single Audit reporting package, including the
Corrective Action Plan, to the Department.
The Contractor must comply with all requirements in the MDCH
Substance Abuse Prevention and Treatment Audit Guidelines, current
edition, as issued by the MDCH Office of Audit.
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 awards must submit the Single Audit
reporting package, management letter, if issued, and Corrective Action
Plan to the Department even if Federal funding received from the
Department results in less than $500,000 in expenditures.
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. Contractors exempt
from the Single Audit requirements that receive less than $500,000 of
total Department grant funding must submit 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.
DCH-0665FY2006 2/05 (W) Part 1 (REVISED 09/23/05) 5 of 16
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.
The Audit Status Notification Letter must be signed by the Contractor's
Financial Director or their designee. Attachment E contains the required
Audit Status Notification Letter. Contractors should not send the
completed letter to the Department with their signed agreement, but
should submit as directed in item 7.
5. Due Date
The Single Audit reporting package, management letter, if one is issued,
and Corrective Action Plan; 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, management letter, and Corrective Action
Plan; 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.
7. Where to Send
A copy of the Single Audit reporting package, management letter, if one
is issued, and Corrective Action Plan; Financial Statement Audit and
management letter, if one is issued; or the Audit Status Notification Letter
must be forwarded to:
DCH-0665FY2006 2/05 (W) Part (REVISED 09/23105) 6 of 16
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
As an alternative to paper filing, the audit report and related
documentation may be submitted to the above address on a CD-ROM in
a Portable Document Format (PDF) compatible with Adobe Acrobat
(read only). The audit report and related documentation should be
assembled as one document in the following order:
a. Financial Statement Audit Report/Single Audit Report,
b. Corrective Action Plan or other information as applicable to MDCH
grants, and
c. Management Letter (Comments and Recommendations).
Another alternative is to send notification to the above address that the
required audit materials may be accessed, in Adobe PDF, from the
Contractor's website.
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. SubrecipientNendor Monitoring
The Contractor must ensure that each of its subrecipients comply with the
Single Audit Act requirements. The Contractor must issue management
decisions on audit findings of their subrecipients as required by OMB Circular
A-133.
The Contractor must also develop a subrecipient monitoring plan that
addresses "during the award monitoring" of subrecipients to provide
reasonable assurance that the subrecipient administers Federal awards in
compliance with laws, regulations, and the provisions of contracts, and that
performance goals are achieved. The subrecipient monitoring plan should
include a risk-based assessment to determine the level of oversight, and
DCH-0665FY2006 2/05 (W) Part I (REVISED 09/23/05) 7 of 16
a
monitoring activities such as reviewing financial and performance reports,
performing site visits, and maintaining regular contact with subrecipients.
The Contractor must monitor vendors for performance of contract
requirements.
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.
J. Software Compliance
The Contractor must ensure that 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.
K. Human Subjects
The Contractor agrees to submit all research involving human subjects, which is
conducted in programs sponsored by the Department, or in programs that
receive funding from or through the State of Michigan, to the Department's
Institutional Review Board (IRB) 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
DCH-0665FY2006 2/05 (W) Part I (REVISED 09/23/05) 8 of 16
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, sexual orientation, 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
persons with disabilities 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 persons with disabilities 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, its employees and its subcontractors:
DCH-0665FY2006 2/05 (W) Part I (REVISED 09/23/05) 9 of 16
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
1. 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 USG 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.
DCH-0665FY2006 2/05 (VV) Part I (REVISED 09/23/05) 10 of 15
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.
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
supported 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 amended, 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.
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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 HIPAA 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 HIPAA 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 II, 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
A. Operating Advance
The Department will not issue an operating advance under this Agreement.
B. Reimbursement Method
The Department will make prepayments equal to the Contractor's prepayment
schedule that has been approved by the Department and the Contractor. The
prepayments will be monthly.
Prepayments may be adjusted after the second quarter based upon
expenditure reports for the first two quarters. Expenditure reporting procedures
are described in Attachment B to this agreement.
DCI-1-0665FY2006 2/05 Co Part I (REVISED 09/23/05) 1213(16
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 match condition exists.
Attachment A to this agreement contains specific local match requirements.
C. Revenues and Expenditures Report Form
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
A copy of each RER form must be submitted by e-mail to:
Michigan Department of Community Health
Office of Drug Control Policy
Denise Murray
E-mail: murrayden@michigan.gov
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 ex enc -dless
of the source of funds. Attachment B contains the RER form. Please note that
the fourth quarter RER form, which would be due October 31, is not
required.
Failure to meet financial reporting responsibilities as identified in this agreement
may result in withholding future payments.
D. Reimbursement Mechanism
All contractors must sign up through the on-line vendor registration process to
receive all State of Michigan payments as Electronic Funds Transfers
(EFT)/Direct Deposits. Vendor registration information is available through the
Department of Management and Budget's web site:
• http://www.cpexpress.state.mi.us/
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.
DCH-0665FY2006 2/05 (W) Part I (REVISED 09/23/05) 13 of 16
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
DCH-0665FY2006 2/05 (W) Part I (REVISED 09/23/05) 14 of 16
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.
Xl. 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 shall 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 connection 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
DCH-0665FY2006 2/05 (W) Part I (REVISED 09/23/05) 15 of 16
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.
DCH-0665FY2006 2/05 (W) Part I (REVISED 09/23/05) 16 of 16
MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
FY 05/06 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 10/1/05 Through
9/30/06:
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
J. 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. This addendum modifies the following sections of Attachment A, Statement of Work:
Item 13(e.) shall be deleted in its entirety.
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 Section:
For the MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
Nick Lyon, Deputy Director Date
Operations Administration
For the CONTRACTOR
Bill Bullard, Chairman, Oakland County Board of Commissioners
Name and Title
Signature Date
X Subrecipient
Vendor
ATTACHMENT A
STATEMENT OF WORK
FY 2006
ATTACHMENT A
STATEMENT OF WORK
Please note: Items in this Statement of Work have been placed into one of three
categories: General; Administrative and Financial; and Services. This categorization is
for convenience of reference only. It is not intended, and should not be interpreted, as
limiting the applicability or scope of any item or items.
General
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. Action Plan Guidelines (APGs) and Action Plan
The CA will carry out its responsibilities under this Agreement consistent with the
CA's FY2005 Action Plan (AP), as approved by the department, which was
submitted in response to the Action Plan Guidelines issued in December 2004 or
as updated by the CA and approved by the department.
Page 1 of 30 FY 2006 (Rev 09/23/05)
. ATTACHMENT A
3. Substance Abuse Prevention and Treatment (SAPT) Block Grant
Requirements and Application to State Funds
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.
Sections from PL 102-321, as amended, that apply to CAs and contractors
include but are not limited to: 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); 1941; 1942(a); 1943(b);
1947(a)(1) and (2).
Selected specific requirements applicable to CAs are as follows:
a. Block Grant funds shall not be used to pay for inpatient hospital services
except under condition specified in federal law.
b. Funds shall not be used to make cash payments to intended recipients of
services.
c. Funds shall not be used to purchase or improve land, purchase, construct, or
permanently improve (other than minor remodeling) any building or any other
facility, or purchase major medical equipment.
d. 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.
e. Funds shall not be used to provide individuals with hypodermic needles or
syringes so that such individuals may use illegal drugs.
f. 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 pay the salary of an individual at a rate in excess
of Level I of the Federal Executive Schedule, or approximately $174,500.
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.
g.
Page 2 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
4. Staff Qualifications and Professional Development
ODCP, in cooperation with CAs and providers, is preparing to move toward
recognizing the International Certification Reciprocity Consortium (ICRC)
certification standards as applicable to the MDCH-funded public substance
abuse provider network. Recognition will be contingent on the completion of
planning and analysis, and the establishment of reasonable standards. Pending
implementation of these standards, the CA must:
a. Adopt and disseminate policy with respect to required minimum professional
qualifications for direct service personnel in the CA network's Access
Management System and in all treatment providers, applicable both to
salaried or contractual personnel. The CA may continue its current policies, if
these policies are consistent with the requirements of the Agreement, or the
CA may adopt new policies. ODCP encourages the CA to work with the other
CAs to assure statewide coordination of policy concerning professional
qualifications, pending adoption of the ICRC standards.
b. Require all treatment provider panel members to establish and maintain a
credentials file on all salaried or contractual staff who are providing clinical
services.
c. 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. Require professional development of counselors and all health care workers
relative to HIV/AIDS prevention and the prevention of other serious
communicable diseases.
5. Licensure of Subcontractors
The CA shall enter into subcontracts for prevention and treatment services only
with providers appropriately licensed for the service provided as required by
Section 6231 of P.A. 368 of 1978, as amended. The CA must ensure that
network providers residing and providing services in bordering states meet all
applicable licensing and certification requirements within their states as well as
that staff are credentialed and providers accredited per the requirements of this
Agreement.
6. Accreditation of Subcontractors
The CA shall enter into subcontracts for outpatient, intensive outpatient,
Methadone, sub-acute detoxification and residential 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 Rehabilitation Facilities (CARF); the American
Osteopathic Association (AOA); Council on Accreditation of Services for Families
Page 3 of 30 FY2006 (Rev 09.23.05)
• ATTACHMENT A
and Children (COA); or National Committee on Quality Assurance (NCQA). The
CA must determine compliance through review of original correspondence from
accreditation bodies to providers.
Accreditation is not needed in order to provide AMS services, whether these
services are operated by a CA or under contract to a CA. Accreditation is
required for AMS providers that also provide treatment services.
7. SAMHSA/DHHS License
The federal awarding agency, Substance Abuse and Mental Health Services
Administration/Department of Health and Human Services (SAMHSNDHHS),
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, sub-grant, or
contract under a grant or sub-grant; and (b) Any rights of copyright to which a
grantee, sub-grantee or a contractor purchases ownership with grant support.
8. 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.
9. Monitoring of Subcontractors
The CA is required to assure that subcontractors comply with all applicable
requirements contained in this agreement. To this end, the CA must adopt
written policy and to implement procedures regarding monitoring of
subcontractors. The monitoring policy and procedures must be consistent with
requirements in this agreement, with the current MDCH substance abuse audit
guidelines, and with applicable OMB circulars. The CA must prepare a report of
monitoring findings, and must make this report available to the public at least
biannually.
Administrative and Financial
1. Match Rules
Pursuant to Section 6213 of Public Act No. 368 of 1978, as amended, Michigan
has promulgated match requirement rules. 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 (see
Page 4 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
Attachment B to the Agreement) - 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.
2. Reporting Fees and Collections Revenues
The CA is required to report on the Revenue and Expenditures Report all fees
and collections revenue received by the CA and all fees and collections revenue
received and reported by its contracted services providers (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.
3. Management of Department-Administered Funds
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.
4. Sliding Fee Scale
The CA shall implement a sliding fee scale. All treatment providers shall utilize
the scale. The CA must adopt written policies and implement procedures for
determining when an individual has no ability to pay for services and for
determining when payment liability is to be waived.
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, whichever occurs sooner.
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.
Page 5 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
The CA sliding fee scale must be applied to all persons (except Medicaid,
MIChild, and ABW recipients) seeking substance abuse services funded in whole
or in part by the CA. The CA has the option to decide if fees will be charged for
AMS services. The CA may choose to charge no fees for AMS services. If the
CA charges for AMS services, the same sliding fee scale as applied to treatment
services must be used.
With respect to AMS 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.
The CA must assure that all available sources of payments are identified and
applied prior to the use of Department-administered funds. 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.
5. 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.
6. 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 access to AMS and/or treatment services, consistent with the requirements
of this Agreement, regardless of their residency. However, for non-priority
populations, 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.
7. 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.
Page 6 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
8. Reimbursement Rates for Community Grant, Medicaid and Other 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, Medicaid funds, or other Department administered funds, including
Adult Benefit Waiver (ABVV) and MIChild funds.
9. Reimbursement for Primary Health Care with HIV Early Intervention
Program (EIP) Funds
HIV Early Intervention Program funds shall not be used to purchase primary
health care unless the Department approves such use in writing.
10. Minimum Criteria for Reimbursing for Services to Persons with Co-
Occurring Disorders
Department funds made available to the CA through this Agreement, and which
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 PIHP. The CA may also reimburse a provider, other than
a CMHSP or PIHP, 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
the CMHSP (or other provider) must meet all minimum qualifications, including
licensure, accreditation and data reporting.
11. 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.
12. Notice of Funding Excess or Insufficiency
The CA must advise the Department in writing by May I if the amount of
Department funding may not be used in its entirety or appears to be insufficient.
13. Subcontractor Information to be Retained at the CA
a. Budgeting Information for Each Service.
b. Documentation of How Fixed Unit Rates Were Established:
Page 7 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
The CA shall maintain documentation regarding how each of the unit rates
used in its contracts was established. The process of establishing and
adopting rates must be consistent with criteria in OMB Circular A-87 or A-
122, whichever is applicable, and with the requirements of individual fund
sources.
c. Indirect Cost Documentation:
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 I, 2.B., and in Attachment B to this Agreement.
e. Fidelity Bonding Documentation:
The CA shall maintain fidelity bonding documentation.
14. Reporting Requirements
a. General 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.
1. 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, or 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.
2. 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.
3. Reports must be submitted on the form and in the format specified
in this Agreement (if form and format are specified).
b. Legislative/Entity Inventory Reports (LEIRs) and Final Financial
Reports (RERs)
If the contractor does not submit the LER or the final RER within fifteen
days of the due date, the department may withhold from the current year
funding an amount equal to five percent of that funding (not to exceed
$100,000) until the department receives the required report. The
department may retain the amount withheld if the contractor is more than
sixty days delinquent in meeting the filing requirements.
Page 8 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
c. Data Reporting Timeliness and Completeness Standards
MDCH monitors the timeliness of submission for all required reports.
Reports that arrive after the established due date are recorded as late. If
the submission arrives more than 5 days past due, a letter will be sent to
the CA Director to notify the CA of the lack of compliance with the
published due date. Sanctions for non-compliance (depending on the
severity and frequency) may include a corrective action plan or may
include an adjustment in pre-payments
For data transactions that are submitted via the Date Exchange Gateway
(DEG), including admission, discharge, and encounter batches, the
processing system logs the dates and times the batches were transferred
and processed. When the system is in production, monthly submissions
by the CAs are required. Data submissions are monitored daily by MDCH
staff.
d. Data Completeness
The CA is responsible for submitting 100% of required records. Initial
submissions combined with error corrections and resubmissions must
result in an accuracy rate of 100%.
On the second working day of every calendar month, the Department will
send to the CA an error rate or acceptance rate notification based on the
number of errors in its error master file. This notification will serve as an
advisory for both MDCH and the CA.
After six months, the CA is required to send in a live count (e-mail
transaction) from its information system noting the first six-month total
counts of admissions, discharges, and encounters (by code). This is
required for consultation purposes to identify whether the CA's
submissions to MDCH show shortages compared to its local counts. The
Department will notify the CA of its acceptance rate. If the CA's
acceptance rates are less than 98% for admission/discharge data and less
than 95% for encounters, the Department will notify the CA that
improvement is needed.
After the close of the fiscal year, the above steps must be repeated. If the
CA's acceptance rates are less than 98% for admission/discharge data
and less than 95% for encounters, the Department will cite the CA as part
of the Department's data completeness audit. Plans of correction will be
required.
Page 9 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
e. Critical Incidents and Sentinel Events
The CA must require all of its residential treatment providers to prepare
and file critical incident reports and sentinel event reports that include the
following components:
1. Provider determination whether critical incidents are sentinel
events.
2. Following identification as a sentinel event, the provider must
ensure that a root cause analysis or investigation takes place.
3. Based on the outcome of the analysis or investigation, the provider
must ensure that a plan of action is 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 provider may
prepare a rationale for not pursuing a preventive plan.
The CA is responsible for oversight of the above processes.
Requirements for reporting data on Sentinel Events are contained in
Attachment F. These reporting requirements are narrower in scope than
the responsibility to identify and follow up on critical incidents and sentinel
events.
A Critical Incident is any of the following that should be reviewed to
determine whether it meets the criteria for a sentinel event below:
1. Death of a recipient.
2. Serious illness requiring admission to hospital.
3. Alleged cause of abuse or neglect.
4. Accident resulting in injury to recipient requiring emergency room
visit or hospital admission.
5. Behavioral episode.
6. Arrest and/or conviction.
7. Medication error.
A Sentinel Event is an "unexpected occurrence involving death or serious
physical or psychological injury", or the risk thereof. Serious injury
specifically includes loss of limb or function. The phrase, "or risk thereof"
includes any process variation for which a recurrence would carry a
significant chance of a serious adverse outcome." (JCAHO, 1998)
Page 10 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
15. 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.
Services
1. General Services
A. 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 for persons who do not have the ability to pay.
B. Persons Associated with the Corrections System
When the CA or its AMS services 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 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 AMS services or from a panel provider,
these self-referrals must be handled like any other self-referral to the
MDCH-funded network. AMS or provider staff may seek to obtain
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.
Page 11 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
The CA may collaborate with MDOC, and with the Office of Community
Corrections (OCC) within MDOC, on the purchase of substance abuse
services and supports. This may include collaborative purchasing from the
same providers, and for the same clients. In such situations, the CA must
assure that:
1. All collaborative purchasing is supported by written agreements
among the participants.
2. Rates paid to providers, whether by a single purchaser or two or
more purchasers, do not exceed provider costs.
3. Rates paid to providers are documented and are developed
consistent with applicable OMB Circular(s).
4. No duplication of payment occurs.
C. State Disability Assistance (SDA)
MDCH continues to allocate State Disability Assistance funding and to
delegate management of this funding to the CA. The SDA funding is
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 four 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 Michigan Department of
Human Services (MDHS) for SDA funding, the CA where the provider is
located must arrange for assessment and authorization for SDA room and
board funding and must 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-four dollars ($24.00) 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 MDHS; assessed by the regional AMS
services to be in need of residential treatment services; authorized by the
CA (or AMS) for residential treatment when the CA expects to reimburse
Page 12 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
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.
D. Case Management and Care Management Reimbursement
The cost of case management services may be built into the
reimbursement rates for licensed providers, including those services
provided at designated women's services programs. Case management
must be intended to assist clients in making best use of services, supports
and benefits, on behalf of the clients.
The CA may choose to pay for case management as a separate service.
Separate case management services must be reported as an encounter
under the H0006 universal CPT code. Case management services and
provider agencies must meet the criteria stated in the current APG, unless
the CA obtains a written waiver from the Department.
The CA may also pay for care management. Care management is in
recognition that some clients represent such service or financial risk that
closer monitoring of individual cases is warranted. Care management
must be purchased and reported consistent with the instructions for the
Administrative Expenditures Report in Attachment B to this agreement.
E. Persons Involved With the Michigan Department of Human Services
(MDHS)
The CA must work with the MDHS office(s) in its region on issues related
to prevention, access, assessment and treatment of persons involved with
MDHS, including families in the child welfare system and public assistance
recipients.
F. Primary Care Coordination
The CA must take all appropriate steps to assure that substance 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.
Treatment case files must include, at minimum, the primary care
physician's name and address, a signed waiver release of information for
purposes of coordination, or a statement that the client has refused to sign
this waiver.
Page 13 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
G. 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:
1. The CA's identification and assessment of the cultural needs of
potential and active clients based on population served.
2. The CA's identification of how access to services is facilitated for
persons with diverse cultural backgrounds and LEP.
3. The CA's identification standards for the recruitment and hiring of
culturally competent staff members.
4. 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.
5. The CA's process for ensuring that contractual providers comply
with all applicable requirements concerning the provision of
culturally competent services.
6. The CA's process for annually assessing its compliance with the
CA's cultural competence plan.
H. Charitable Choice
The September 30, 2003 Federal Register (45 CFR part 96) contains
federal Charitable Choice SAPT block grant regulations which apply to
both prevention and treatment providers/programs. In summary, the
regulations require 1) that the designation of religious (or faith-based)
organizations as such be based on the organization's self-identification as
religious (or faith based), 2) that these organizations are eligible to
participate as providers—e.g. a "level playing field" with regard to
participating in the CA provider panel, 3) that a program beneficiary
receiving services from such an organization who objects to the religious
character of a program has a right to notice, referral and alternative
services which meet standards of timeliness, capacity, accessibility and
equivalency—and ensuring contact to this alternative provider, 4) other
requirements, including-exclusion of inherently religious activities and non-
discrimination.
The CA is required to comply with all applicable requirements of the
Charitable Choice regulations. The CA must ensure that treatment clients
and prevention service recipients are notified of their right to request
alternative services. Notice may be provided by the AMS or by providers
that are faith-based. Notification must be in the form of the model notice
contained in the final regulations, or the CA may request written approval
from DOH of an equivalent notice.
Page 14 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
The CA must also ensure that its AMS administer the processing of
requests for alternative services.
The model notice contained in the federal regulations is:
"No provider of substance abuse services receiving Federal funds from
the U.S. Substance Abuse and Mental Health Services Administration,
including this organization, may discriminate against you on the basis of
religion, a religious belief, a refusal to hold a religious belief, or a refusal to
actively participate in a religious practice.
If you object to the religious character of this organization, Federal law
gives you the right to a referral to another provider of substance abuse
services. The referral, and your receipt of alternative services, must occur
within a reasonable period of time after you request them. The alternative
provider must be accessible to you and have the capacity to provide
substance abuse services. The services provided to you by the alternative
provider must be of a value not less than the value of the services you
would have received from this organization."
I. Limited English Proficiency
The CAs must insure a current Limited English Proficiency
(LEP) policy is in place and in practice. The CA must also have
documentation that all providers have implemented the required LEP
policy and procedures and are in compliance with related Federal and
State requirements. The LEP policies and procedures must include the
following, as required by the Office of Civil Rights.
1. Procedures for identifying and assessing the language needs of the
CA, individual provider and the geographic area served. Needs
must be based on current local and regional census data, as well
as other state and regional data.
2. Identified range of oral language assistance options appropriate to
the CAs circumstances.
3. How the CA provides notice to LEP persons, in their primary
language, of the right to free language assistance.
4. What staff training and program monitoring is performed related to
LEP policies and procedures.
5. Provisions for written materials in language other than English
where a significant number or percentage of the affected population
needs services or information in a language, other than English, to
communicate effectively.
6. Provisions for language interpreters who are trained and
competent.
7. Statements explaining timely assistance.
Page 15 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
8. Statements explaining there will be no charge to the LEP recipient
for these services.
9. Provisions regarding use of family member and/or friend as a
language interpreter must not be required. Should the consumer
choose to use family or friend as an interpreter, both the offering of
other resources, and the consumer's choice, must be documented
in writing. Availability of consumer family and friends as
translator/interpreter will not waive other LEP requirements herein
described.
2. Treatment Services
A. 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
1.22 Based on clinical information from the 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
Page 16 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
1.2.4 Made by appropriately trained substance abuse
professionals with sufficient clinical experience; and
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
Page 17 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
above, and that are provisional and subject to
modification based on individual clinical needs and
clinical progress.
B. Clinical Eligibility: DSM IV-TR Diagnosis
In order to be eligible for treatment services purchased in whole or part by
state-administered funds under the agreement, 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. This
requirement is not intended to prohibit use of these funds for family
therapy. It is recognized that persons receiving family therapy do not
necessarily have substance use disorders.
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
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
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
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
Page 18 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
304.90
305.90
292.89
292.00
Other (or Unknown) Substance Dependence
Other (or Unknown) Substance Abuse
Other (or Unknown) Substance Intoxication
Other (or Unknown) Substance Withdrawal
C. Satisfaction Surveys
The CA shall assure that satisfaction surveys of persons receiving
treatment are conducted at least once a year by all network
subcontractors providing treatment. Surveys may be conducted by
individual providers or may be conducted centrally by the CA. 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, by provider, available to the public.
D. Adult Benefit Waiver
In consideration for accepting the federal funding pushed to the
Coordinating Agency (CA) for the State Medical Program (SMP) eligible
under an approved Health Insurance Flexibility and Accountability (HIFA)
Adult Benefit Waiver (ABVV), 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 .6961) based on program enrollment. The
amount of general fund dollars applied by the CA to program costs shall
equal .3039 percent of the total PEPM during the contract year following
the date of program initiation. In the event that program costs are less
than 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.
Use of these funds must be consistent with requirements pertaining to
these other State Agreement funds.
Page 19 of 30 FY2006 (Rev 09.23.05)
' ATTACHMENT A
ABW Covered and Discretionary Services
ABW covered and discretionary services, as contained in the Medicaid
Provider Manual, are listed below.
Covered Services:
1. Initial assessment, diagnostic evaluation, referral and patient
placement;
2. Outpatient Treatment;
3. Intensive Outpatient Treatment; and
4. Federal Food and Drug Administration (FDA) approved
pharmacological supports for Methadone.
ABW Discretionary Services:
1. 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).
Page 20 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
Access Timeliness
Access timeliness requirements are the same as those applicable to
Medicaid substance abuse services, as specified in the contract between
MDCH and the P1HPs. Access must be expedited when appropriate
based on the presenting characteristics of individuals.
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 "ABVV" for Adult Benefits Waiver.
The combined federal share and the GE 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 HIPAA 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:
1. Meet the medical necessity criteria contained in this Agreement;
2. Are based on individualized determination of need; and
Page 21 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
3, Meet the AMS 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 treatment plan that emphasizes appropriate treatment and
recovery,
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 Community Grant program,
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.
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,
AMS service requirements, and best practice standards.
The CA may authorize additional units based on these same criteria plus:
1. The beneficiary's commitment to treatment based on participation
and attendance;
2. Progress in meeting goals in the individualized treatment plan, and
3. Evidence that the beneficiary will benefit from additional units.
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, AMS
service requirements, and best practice standards.
The CA may authorize additional units based on these same criteria plus:
Page 22 of 30 FY2006 (Rev 09.23.05)
• ATTACHMENT A
1. The beneficiary's commitment to treatment based on participation
and attendance; and
2. Progress in meeting goals in the individualized treatment plan; and
3. Evidence that the beneficiary will benefit from additional units.
FDA Approved Pharmacological Supports for Methadone
The CA may authorize up to ninety (90) days of Methadone treatment
based on medical necessity criteria, individualized determination of need,
AMS service requirements, best practice standards, and the criteria,
contained in this Agreement, for Opioid dependent substance abuse
treatment with Methadone (Treatment Policy-05 contained in Attachment
F).
The CA may authorize additional treatment in increments of up to ninety
(90) days each based on these same criteria.
E. Intensive Outpatient Treatment — Weekly Format
The CA may purchase Intensive outpatient treatment (10P) if the
treatment consists of regularly scheduled treatment, usually group
therapy, within a structured program, for at least three days and at least
nine hours per week.
F. Services for pregnant women, women with dependent children,
women attempting to regain custody and their children
The CA must assure that contractors screen and/or assess pregnant
women, women with dependent children, and women attempting to regain
custody of their children to determine whether these women need and
want the defined federal services that are listed below. All federally
mandated services must be made available within each CA region.
Financial Requirements
The CA has been assigned an expenditure target for women's specialty
services, in the CA's allocation letter. State general fund dollars and the
state share of Medicaid dollars, as well as SAPT Block Grant dollars, can
be counted toward the expenditure target. CAs must report on their
RERs, in the Women's Specialty column, all allowable expenditures for
women's specialty services, and only allowable expenditures.
Requirements Regarding Providers
Women's specialty services may only be provided by providers that are
gender-competent and that meet standard panel eligibility requirements.
Page 23 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
The provider may be designated by ODCP as women's specialty
providers, but such designation is not required. The CA must continue to
provide choice from a list of providers who offer gender competent
treatment and identify providers that provide the additional services
specified in the federal requirements.
Federal Requirements
Federal requirements are contained in 45 CRF Part 96) section 96.124,
and may be summarized as:
Treatment programs receiving funding from the Block Grant set aside for
pregnant women and women with dependent children must provide or
arrange for the following:
1. Primary medical care for women, including referral for prenatal care
if pregnant, and while the women are receiving such treatment,
child care;
2. Primary pediatric care for their children, including immunizations
3. Gender specific substance abuse treatment and other therapeutic
interventions for women, which may address issues of
relationships, sexual and physical abuse, parenting, and child care
while the women are receiving these services;
4. Therapeutic interventions for children in custody of women in
treatment, which may, among other things, address their
developmental needs, issues of sexual and physical abuse, and
neglect; and
5. Sufficient case management and transportation to ensure that
women and their dependent children have access to the above
mentioned services. Women with dependent children are defined to
include women in treatment who are attempting to regain custody
of their children.
G. Communicable Diseases
The following material replaces the HIV Early Intervention Project
Guidelines that were in contract Attachment F.3 in FY 2005. Updated
guidelines are currently under development.
In accordance with federal block grant requirements, tuberculosis (TB)
treatment must be made available for persons receiving substance abuse
services either directly or through referral. If referred, responsibility
extends to ensuring that the agency to which the client is referred has the
capacity to provide these services.
Page 24 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
The CA must have a process in place so that all substance abuse clients
entering treatment have been appropriately screened for risk of HIV/AIDS,
Sexually Transmitted Disease (STD), TB, Hepatitis and other
communicable diseases and are provided basic information about risk.
For those clients identified with high-risk behaviors, additional information
about the resources available, health education and risk reduction
activities, and referral to testing and treatment (with follow-up) must be
made available to them.
CAs must provide for access to Hepatitis C testing for all clients with a
history of IDU and access to STD and HIV testing for all pregnant women
presenting for treatment. CAs must also assure that all clients entering
residential treatment will be tested for TB upon admission, and that test
results be known within five days of admission. In the case of clients who
are at high risk for TB, the CA must assure that universal precautions are
followed by the residential provider until test results are known. Clients
who exhibit symptoms of active TB need to be given a surgical mask to
wear and placed in respiratory isolation immediately. If facility does not
have the capability to place people in respiratory isolation, the client
should be moved to a hospital or other location where they will not be a
danger to those around them, until test results are known. Information on
universal precautions may be found at
http://www.cdc.gov/mmwr/PDF/rr/rr4508.pdf.
CA must assure staff knowledge and skills in the provider network are
adequate to meet communicable disease-related requirements through
training or other means, and use as their guidance the APG Guidelines
issued December 2004. All activity related to HIV/AIDS must be
conducted in accordance with federal and MDCH/HAPIS requirements.
Collection and submission of client data must be consistent with HAPIS
data collection methods, including the Uniform Reporting System (URS)
CareWare for case management level data and the HIV Event System
(HES) for Counseling, Testing and Referral (CTR) and other prevention
and risk reduction services. URS/CareWare quarterly summary reports
are due to HAPIS by the 15 th day of the month following the end of a
quarter. HES data is required to be reported in real time on the web-
based system at www.hapis.org . User name and password information
for HIV providers to enter data is available by contacting HAPIS. CAs may
request a summary report of their provider data on a quarterly basis by
contacting the ODCP Communicable Disease Specialist.
Page 25 of 30 FY2006 (Rev 09.23.05)
• ATTACHMENT A
Communicable disease priority populations include all clients with a
history of !DU and pregnant women presenting for treatment. Additionally,
women, African American males and communities of color are considered
at higher risk.
Funds may be used for counseling, testing and referral when the client is
not eligible for these services through other funding sources or the
counseling and testing services are an integral component of the
substance abuse treatment program.
3. Prevention Services
A. Prevention Requirements
Prevention funds may be used for needs assessment and related
activities. All prevention services must be based on a formal local needs
assessment.
Based on needs assessment, prevention activities must be targeted to
high-risk groups and must be directed to those at greatest risk of
substance abuse and/or most in need of services within these high-risk
groups. CAs are not required to implement prevention programming for all
high-risk groups. The CA may also provide targeted prevention services to
the general population.
The high risk subgroups include but are not limited to: children of
substance abusers; pregnant women/teens; drop-outs; violent and
delinquent youth; persons with mental health problems; economically
disadvantaged citizens; persons who are disabled; victims of abuse;
persons already using substances; and homeless and/or runaway youth.
Additionally, children exposed prenatally to ATOD are identified as a high-
risk subgroup.
Prevention services must be provided through strategies identified by
CSAP. Prevention-related funding limitations the CA must adhere to are:
1) A maximum of 35% of prevention funding may be used for school
based activities, 2) CA expenditure requirements for prevention, including
Synar, as stipulated in the CA's allocation letter, 3) 90% of prevention
expenditures are expected to be directed to programs which are
implemented as a result of an evidence-based decision making process,
and 4) Alternative strategy activities, if provided must reflect evidence-
based approaches and best practices such as multi-generational and adult
to youth mentoring.
FY2006 (Rev 09.23.05) Page 26 of 30
• ATTACHMENT A
The prevention planning process, including local needs assessment, used
by the CA must encompass the following principles:
1. Development of a plan that is responsive to community needs,
interests and capacity, and is based on a formal needs assessment
process.
2. Is collaborative in nature representing coordination of resources
and activities with other primary prevention providers—e.g. local
health departments, community collaboratives, and the Family
Independence Agency's prevention programs for women, children
and families, and older adults;
3. Be supportive of community coalitions
4. Provide regional coverage in relation to need and priority
5. Use federally defined strategies
6. Implement and/or select prevention interventions (programs)
through a science based process
7. Be carried out by competent, licensed providers
8. Target high risk populations
9. Incorporate key performance targets, outcomes and milestones
against which to measure progress
10. Include a process for monitoring, quality assurance and adjusting
program operations on the basis of program performance.
11. Be provided in a culturally competent manner with outreach to
populations of color and otherwise under-represented groups.
Prevention strategies identified by CSAP are information dissemination;
education; alternatives when these reflect evidence-based approaches and best
practices such as multi-generational and adult to youth mentoring; problem
identification and referral; community based processes; and environmental.
State allocations may be used for information dissemination when part of a multi-
faceted regional prevention strategy, however not for independent, stand-alone
activity.
The CA must monitor and evaluate prevention programs at least annually to
determine if the program outcomes, milestones and other indicators are
achieved, as well as compliance with state and federal requirements. A written
monitoring procedure which includes requirements for corrective action plans to
address issues of concern with a provider is required. The CA must also insure
integrity to prevention best practice models including those related to planning
prevention interventions such as risk/protective factor assessment, community
assets/resource assessment, levels of community support, evaluation, etc.
Page 27 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
B. Youth Access To Tobacco Activity and Synar Requirements
Section 1922 of the Public Law 102-321, as amended, requires that strategies be
implemented which discourage the use of tobacco products by individuals to
whom it is unlawful to sell or distribute such products. The penalty for not
meeting access restrictions with regard to the sale of tobacco is up to 40 percent
of the SAPT Block Grant award.
Current best practice strategies instituted and required by ODCP to reduce youth
access to tobacco are under review and may be revised in the near future.
Until such time that revised requirements are developed please note the
following remain required and/or recommended:
Formal Synar Inspections
All CAs must conduct formal Synar Inspections at the time specified by ODCP.
All formal Synar inspections must be conducted in accordance with the protocol
provided by ODCP.
Tobacco Retailer Inspections
ODCP recommends that CAs 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.
ODCP recommends that the CAs conduct inspections that include a minimum of
10 percent of retailers on the Master List. Reimbursement rates may be
negotiated but ODCP recommends a rate that does not exceed $56.
Please note that SAPT Block Grant Funds cannot be used for law enforcement
inspections. ODCP assumes responsibility for monitoring compliance with this
condition.
Inspections must be conducted using the FY 2005 formal Synar compliance
check protocols, 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.
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 percent of the
tobacco retailers in the CA's region, using the ODCP-provided protocol. An
Page 28 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
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.
List of Tobacco Vendors
The CA must annually review, determine the accuracy, and correct the list of
tobacco vendors within the CA region. This must include: a) a contact, by phone,
or site visit, to each retailer on their list to confirm whether that retailer continues
to sell tobacco products; to confirm the business is still in operation and b) the
CA must identify and include in the listing new tobacco vendors and c) provide an
updated list of vendors in the format specified by the department. This may be
carried out in conjunction with the Designated Youth Tobacco Use
Representative or in conjunction with agencies listed above.
Required Reports
1) An updated retailer listing is due on March 31, 2006. 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 must be sent to MDCH/Office of Drug
Control Policy, Substance Abuse Contract Management Section.
2) An annual Youth Access to Tobacco Activity Report is due January 31, 2006.
See Attachment C.
C. CA Responsibility for SIG Providers
The CA will subcontract with the State Incentive Grant (SIG) provider(s) specified
by the department, at the funding award level(s) specified by the department.
These specifications are contained in the CA's allocation letter. The CA will have
no authority or responsibility concerning provider plans of work, performance of
work, or reporting on plans of work. The department will enter into separate
agreements with SIG providers.
The CA will reimburse SIG providers based on standard CA billing and
reimbursement procedures. The CA subcontract will require SIG providers to
attest that each billing is consistent with all requirements contained in the SIG
Page 29 of 30 FY2006 (Rev 09.23.05)
ATTACHMENT A
agreement between the Department and the providers, and with all applicable
financial requirements. The CA will charge no administrative costs to the SIG
allocation.
Budget and expenditure reporting requirements for SIG are as found in
Attachment B to this agreement.
The CA may conduct provider reviews, including on-site reviews, pertaining to its
fiduciary responsibility. The CA will notify its contract manager when any on-site
reviews are scheduled, and will notify the contract manager of the findings of any
such reviews.
The Department will require that SIG providers provide a copy to the CA of all
program activity and evaluation reports. The Department will copy the CA on
written communications sent to SIG providers. The Department will notify the CA
of scheduled SIG site reviews, trainings, and other events, and will invite the CA
to attend these events.
D. 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.
Page 30 of 30 FY2006 (Rev 09.23.05)
yuno/uA L21 on
Exhibit A
Face Page
Revenues and Expenditures Report Form
Michigan Department of Community Health
Office of Drug Control Policy
— Contractor Name Federal ID No. Date Prepared
36-6004876w 08/29105 OAKLAND COUNTY HEALTH DIVISION Budget Period Page Number(s)
Mailing Address (Number and Street) FROM: 10/0112005 1 of 4
250 Elizabeth Lake Road TO: 9130/2006 Contract No. (enter number)
Contract Agreement (check one)
City State ZIP Code Amendment No. (enter number) el Original
Pontiac nu 41.8341 D Amendment
2 Initial Budget 0 October-December • January-March Submission Type (check one):
0 April-June 0 July-September 0 Final Budget
Quarterly Reconciliation $ a4 1101billrik t c ID 1 „,i .,1 it IN' ii (For State-Administered Fund Only-Section A) lir . , 1 glyAillfi 1'0 ,' ' lc' , „. PI, 'ilk !IP IS 1
' '5n n' i ,. 0 Total Prepayments YTD: $0 1.
/41,i,, la a o u, ', 1 . to a iiiii I'd M. .a,n.. jay ., 7, i
IIII
Total Expenditures YTD: $0 111 1 . ^4 I. il kW; vpil iii, i 11:
'Ordl le, )1 , 11 OIL ,. F-Y11;; I 4 !Egil 71 li l, II; Balance: $0 1” 1 " 1;1 P 4, 1.fir,i1,3;11Mii5V itsa I - tl; 1 6 giO AN h
CERTIFICATION SECTION __..
CERTIFICATION: I certify that the Women's Specialty Services expenditures for the fiscal year are reported accurately, as entered
on Page 3, Column 9.
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 '!,-'" ature Date 08129/2005 Title MANAGER, FISCAL ...
SERVICES
.1 .1 1 /7
Contaat Perso i ... :".7 7 OS i IE '
of Telephone Number and E-mail Address
248-858-6107
kosikseco.oakland.rni.us
Revenues/Expenditures Report Form FY 2006 (i Page 1 of 4
$4,464,354
$176,391
A. State Agreement
1. Community Grant
2. SDA
3. SIG
4. Methamphetamine
A. Subtotal $0 $0 $0 $0 $4,640,745
B. Subtotal $0 $0 $0 $0 $1,820,000
C. ABW Current Year REM—Federal
Share Only (Subtotal)
MIChild Current siearlstPM
(Subtotal)
$93,000
$15,000
E. LOCAL
1. Current Year PA2 $1,574,263
2. PA2 Fund Balance
3. Other Local $550,000
E. Subtotal $0 $0 $0 $0 $2,124,263
Grand Total of Subtotals A-G $01 $01 $01 $0 $9,343,208
Contractor Name: Oakland County Health Division
Address: 250 Elizabeth Lake Road Pontiac Mi 48341
Revenues
Budget Period
To: 9/30/06
Contract #: IAmd. #:
Submission Type: Initial Budget
Expenditures
From: 1011/05
Funds Source (Column 1) Initial Annual Budget Plan
2)
Current Annual Budget
Plan (3) Year-to-Date (5) Balance (6) Current Quarter (4)
B. Medicaid
1. Current Year PEPM (Federal & State)
a. Federal share only for Women's
Specialty
b. State share only for Women's
Specialty
2 Reinvestment Savings
$1,714,000
$49,020
$36,980
$20,000
$150,2001
$500,000
F. Fees & Collections (Subtotal)
utner Lontracts e oources touotoilif
1SAMHSA
MDCH/ODCP REVENUES AND EXPENDITURES REPORT FORM-COMPOSITE
Revenues/Expenditures Report Form FY 2006 (rev. 08/04/05) Page 2 of 4
EXPENDITURE DETAIL Administration Treatment Prevention Women's Specialty
Planned (2) YTD/Final (3) I Planned (4) 1 YTD/Final (5) I Planned (6) 1 YTD/Final (7) I Planned (8) YTD/Final (9)
$319,917 $2,844,978
$176,391
$931,339 $44,020
1 Current Year PEPM (Federal & State) $190,000 $1,524,000
a. Federal share only for Women's Specialty
b. State share only for Women's Specialty
$49,020
$36,980
2. Reinvestment Savings $20,000
B. Subtotal
t. ABW Current Year PEPM--Federal Share
I Only (Subtotal)
$190,000 $01 $1,524,000 $01 $20,000 $01 $86,000 $0
$190,0001 $01 $1,442,2411 $01 $492,0221 $01 $01 $0
$6,0001 1 $143,0001 1 $5001 I $500
$500,000
MDCH1ODCP REVENUES AND EXPENDITURES REPORT FORM
Contractor Name: Oakland County Health Division
Address: 250 Elizabeth Lake Road Pontiac Mi 48341
Budget Period 'Contract #: Vrnd. #: Adjusted
From: 1011105 'To: 9/30106 !Submission Type: Initial Budget
Funds Source (Column 1)
A. State Agreement
1. Community Grant
2. SDA
3. SIG
4. Methamphetamine
"Adcfg: Ilte,t5My'
A. Subtotal
B. Medicaid
$319,9171 $01 $3,021,3691 $01 $931,339 $44,0201 $0j
D. MIChild Current Year PEPM (Subtotal)
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
15,000
$1,442,2411 1 $132,022
$01 I $o
3. Other Local 1 $190,000 $360,000
$705,917
E. Subtotal
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
Grand Total of Subtotals A-G val $6,145,6101 $01 $1,943,8611 $01 $130,5201 $0
Revenues/Expenditures Report Form FY 2006 (rev. 08/04/05) Page 3 of. 4
Amd. #: Budget Period 'Contract #: Contractor Name: Oakland County Health Division
EXPENDITURE DETAIL
Funds Source (Column 1)
HIV ElParaining
Planned (2) I '(ID/Final (3)
ABW
Planned (4) 1 '(M/Final (5)
Other
Planned (6) 1 TM/Final (7) Planned (8) TrD/Final (9)
Other
S84,602 $239,498
$o $0 $0 $0 $01 $84,602 A. Subtotal
B. Medicaid
1. Current Year PEPM
$239,498
B. Subtotal
tr7 t7crgiir rtgarr6=-6-5ri•
Only (Subtotal)
$0 $0
$93,000
MDCH/ODCP REVENUES AND EXPENDITURES REPORT FORM
Address: 250 Elizabeth Lake Road Pontiac Mi 48341 From: 10/1/05 To: 9130/06 'Submission Type: Initial Budget
A. State Agreement
1. Community Grant
2. SDA
3. SIG
4. Methamphetamine
"ACctg,,Dse Only
2. Reinvestment Savings
D. MIChild Current Year PEPM (Subtotal)
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
E. Subtotal $01 $01 $01 $0
F. Fees & Collections (Subtotal) I $200
G. Other Contracts & Sources (Subtotal)
$0
$239,698
Grand Total of Subtotals A-G $01 $177,6021 $01 $01 $01 $01 $0
Revenues/Expenditures Report Form FY 2006 (rev. 06104/05) Page 4 ur 4
ATTACHMENT B
REVENUE AND EXPENDITURES REPORT
FORM/ INSTRUCTIONS,
PROGRAM BUDGET SUMMARY (B.1),
EQUIPMENT INVENTORY SCHEDULE (B.2),
AND
ADMINISTRATION EXPENDITURES REPORT
FORM/INSTRUCTIONS (B.3)
' ATTACHMENT B.1
PROGRAM BUDGET SUMMARY
View at 100% or Larger MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
Use WHOLE DOLLARS Only
PROGRAM DATE PREPARED Page 1 Of
Substance Abuse Services 09/02/05 1 i 1
CONTRACTOR NAME BUDGET PERIOD
Oakland County Health Division From: 10/01/05 To: 09/30/06
MAILING ADDRESS (Number and Street) BUDGET AGREEMENT ' AMENDMENT #
250 Elizabeth Lake Road, Suite 1550 X ORIGINAL r.-1 AMENDMENT
CITY STATE 1 ZIP CODE FEDERAL ID NUMBER
Pontiac MI 48341 38-6004876
EXPENDITURE CATEGORY TOTAL BUDGET (I iiiiiiiiiikam
1.SALARIES & WAGES $0
2.FRINGE BENEFITS $0 .
3.TRAVEL $0
_ 4.SUPPLIES & MATERIALS $0
5.CONTRACTUAL $0
Subcontracts/Subrecipients)
6.EQUIPMENT 0
$9,343,208
t
8. TOTAL DIRECT EXPENDITURES $0 $0 so $9,343,208
(Sum of Lines 1-7)
. 9. INDIRECT COSTS: Rate #1 % $0
INDIRECT COSTS: Rate #2 % $0
10. TOTAL EXPENDITURES $0 $0 $0 1 $9,343,208
SOURCE OF FUNDS
11. FEES & COLLECTIONS $150,200 ,
12. STATE AGREEMENT
$4,640,745 _
13. LOCAL $2,124,263
14. FEDERAL ,
Medicaid $1,820,000
ABW $93,000
MIChild $15,000
Other Contracts & Sources $500,000
16. TOTAL FUNDING $0 $0 $0 $9,343,208
AUTHORITY: P.A. 368 of 1978 The Department of Community Health is an equal
COMPLETION: Is Voluntary, but is required as a condition of funding opPortunity employer. services and nrndrams nrewitior
DCI-I-0385(E) (Rev 2-05) (W) 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 complete and forward to this form to the MDCH contract
manager with the final progress report.
Contractor Name: Contract #: Date:
Contractor's Signature: Date:
Attachment 8.3
ADMINISTRATION EXPENDITURES REPORT
Contractor Name: Fiscal Year (enter # below) Contract Number (enter # below)
Address:
TREATMENT
TOTAL CA ADMIN RE CIPIENT REVENUE SOURCE GENERAL PREVENTION AND CARE OTHER EXPENSES RIGHTS ADMIN.
A. State Agreement . .. -
1. Community Grant , , 13- 2. SDA -7. - 3. SIG , r Jr
4. Methamphetamine
5. HIV/EIP
nAcctg. Use Only" 1151111111 ME"
.1...._.ii 111111•111
IIIMMI111.11111111111
A. Subtotal $0 $0 SO .O $0 . _
B. Medicaid ....,..
1. Current Year PEPM (Federal & State)
a, Federal share only for Women's Specialty
b. State share only for Women's Specialty
2. Reinvestment Savings
B. Subtotal $0 $0 $0 $0 $0 $0
C. ABW Current Year PEPM-Federal Share
Only (Subtotal)
D. MIChild Current Year PEPM (Subtotal)
E. LOCAL t. .,,
",-- r'L 1 . Current Year PA2 - / .
, - .,, •., 2. PA2 Fund Balance
3. Other Local
E. Subtotal $0 $0 $0 $0 $0 $0
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
Grand Total of Subtotals A-G
$0 $0 $0 $0 $0 $0
Administration Expenditures Report F Y2006 (08105) Page 1 of 2
Attachment B.3
ADMINISTRATION EXPENDITURES REPORT
Contractor Name: Fiscal Year (enter # below) Contract Number (enter # below)
Address:
I_
Resource Development (Community Grant) Expenditures Estimate Estimated Expenditures
1. Needs Assessment
2. Training
3. Research and Evaluation
4. Outcome/Performance Evaluation Data
5. Quality Assurance'
TOTAL $0.00 ,.
1 Estimate % of expenditures for Prevention (toward Quality Assurance
Functions) = 0.00%
Describe the method by which this estimated % was made:
Administration Expenditures Report F Y2006 (08/05) Page 2 of 2
Attachment B.3
Administration Expenditures Report
Introduction: The purpose of this technical requirement is to provide policy direction
with regard to CA Administration expenditures and specify annual supplemental
expenditure reporting requirements. The information will be used to determine
compliance with federal SAPT block grant administration and application requirements
as well as to develop a consistent framework for reporting and analysis of administrative
costs.
Application: Expenditures of the Coordinating Agency, regardless of revenue source,
that are not payments to the treatment or prevention service provider network for
treatment or prevention services.
CA administration excludes administrative costs of service providers regardless of
service or administrative function. Any provider's indirect (if applicable), overhead and
management costs associated with delivering the service must be reported as program
expenditures.
Requirements: These requirements are consistent with the RER requirements
regarding administrative budgets and expenditures. The CA budget and expenditures
for Administration must be reasonable, prudent and commensurate with meeting the
contractual requirements between MDCH and the CA and must be consistent with OMB
Circular A-87 or A-122 as applicable. If the CA is a local government entity and
administration expenditures include a central cost allocation amount or rate, this
allocation must have been developed consistent with OMB Circular A-87, Attachment C.
Administration costs must be allocated to all funding sources in accordance with relative
benefits received in accordance with applicable OMB Circular cost principles. Further
detail regarding administrative cost distributions for Medicaid is provided on page 7 of
this document.
Special Note-Depreciation. Depreciation expenditures are only allowable as
permitted by GAAP and federal Circular A-87 or A-122 as applicable. Depreciation or a
use allowance is required by A-87 if approval to directly charge a capital asset has not
been granted.
DCH payments are subject to recovery, based on audit findings. Any CA that is a non-
profit entity cannot have a central cost allocation.
General: In keeping with changes made in FY05 to the RER reporting requirements
that eliminated CA reporting by object of expenditure and converted to program
reporting, the CA administration reporting is program and function based as well. It is
required that the CA accounting structure has the capability to both maintain object of
expenditures (e.g. travel, equipment, rent) but also to report these expenditures by
program function defined below as "final" CA Administration Cost Centers.
Page 1 of 8 FY2006 (August 2005)
Attachment B.3
Final CA Administration Cost Centers: All CA administration expenditures must be
reported in one of the following program functions:
• General Administration
• Prevention Administration
• Treatment and Managed Care Administration (including AMS functions as
applicable)
• Recipient Rights
• Other Administrative Costs
The CA's accounting system may incorporate both direct and distributed costs to these
final cost centers. All cost distributions must be consistent with applicable federal
regulations and state contract requirements.
If the CA's accounting system does not directly charge (identify) each expenditure within
these five spending categories as final cost centers, the CA must have a system in
place by which to appropriately distribute expenditures to these categories. This could
be a combination of expenditure object codes and a cost distribution model that meets
OMB Circular requirements as applicable. It may include staff time studies.
Note that RER requirements incorporate the requirement that when there is a central
cost allocation, the CA Chief Executive Office or Chief Financial Officer must submit and
provide Certification as to the appropriateness of the cost allocation process. The CA
central cost allocation plan certification form must be submitted when introduced and
when revised or every two years, whichever is sooner.
General Administration. General administration includes the six expenditure
categories defined as administration by federal block grant requirements. These are
indirect costs, grants and contract management, CA audit, CA policy and procedure
development; personnel management and legislative liaison activities if applicable.
Additionally, general administration includes expenditures for those functions associated
with administering the substance abuse services delivery system that are not otherwise
included in the Prevention, Treatment, Managed Care, or Recipient Rights categories.
It includes executive leadership of the CA. The medical director of the CA should be
reflected in general administration if role of the medical director is to provide overall
leadership to functions such as the development of clinical policies/protocols, treatment
guidelines, level of care criteria, utilization management and utilization review. The
costs of the Medical director's provision of clinical consultation or treatment services
must be reported as Treatment expenditures.
Examples of other expenditures to be included in general administration include CA
membership dues, advertising, insurances, board costs, Advisory Council costs and CA
budget development. Also, when not specific to treatment or prevention services,
examples include interpreter services, community forums and public hearings. Finally,
time spend by the executive leadership in interagency collaboration--which could, for
Page 2 of 8 FY2006 (August 2005)
Attachment B.3
example, include the development and operation of drug courts, integrated treatment
projects, participation in local work groups, collaborating bodies, etc can be included in
the general administration category.
Federal SAPT regulations limit total state-wide block grant general administration
expenditures to 5%. The department will aggregate expenditures and apply the 5% limit
on a statewide basis to this general administration category for the SAPT block grant.
However, it is understood that individual CA expenditures in this category may be above
or below the 5% level for this category depending on budget size, entity need and local
contributions. Accurate reporting of these administrative expenditures is critical to
meeting federal requirements of the federal block grant.
Prevention Administration CA prevention administration expenditures include costs
associated with the administration of prevention services. CA Synar-compliance
activities and other CA administrative expenditures directly attributable to the substance
abuse prevention program should be included in this category.
Additionally, prevention administration includes those CA administrative costs
associated with prevention program site visits, needs assessment, planning, program
development, research and evaluation, reviews conducted in accordance with section
6228(b) of the Public Health Code (PA 368 (1978) as amended), quality assurance and
post employment CA training including training paid by the CA for provider network
staff. Costs associated with proctoring exams or credentialing of prevention staff must
also be included in this expenditure category.
HIV/AIDS EIP administrative costs may be reported under the category which is
appropriate to the internal organization of the CA and the management of the H(V/AIDS
DP program. For example, in some CAs, this program is administered through the
prevention administration and through the treatment administration in other CAs. In the
former, these CA administration expenditures would be reported with prevention; in the
latter, with the treatment/managed care administration expenditures.
Treatment and Managed Care Administration (including AMS).
Both treatment and managed care administration expenditures are combined and
reported as treatment and managed care administration expenditures. It is not,
therefore, necessary to distinguish between treatment or managed care administration
activities such as treatment program site visit administration expenditures vs quality
management expenditures.
a) Treatment: CA treatment administration expenditures include costs associated with
administration of the treatment program including, if employed by the CA, the women's
specialist, the treatment or clinical administrator, and other costs attributable to the
substance abuse treatment program. When performed by treatment administration
staff, costs associated with the development of drug court programs, integrated
Page 3 of 8 FY2006 (August 2005)
Attachment 13,3
treatment projects, participation in local collaborating bodies, etc. should be included in
this category.
Additionally, treatment administration includes those CA administrative costs associated
with treatment program site visits, needs assessment, planning, program development,
research and evaluation, reviews conducted in accordance with section 6228(b) of the
Public Health Code (PA 368 (1978) as amended), quality assurance and post
employment CA training including training paid by the CA for provider network staff.
Costs associated with proctoring exams or credentialing of treatment staff must also be
included in this expenditure category.
H1V/AIDS E1P administrative costs may be reported under the category which is
appropriate to the internal organization of the CA and the management of the HIV/AIDS
EIP program. For example, in some CAs, this program is administered through the
prevention administration and through the treatment administration in other CAs. In the
former, these CA administration expenditures would be reported with prevention; in the
latter, with the treatment/managed care administration expenditures.
b) Managed Care Administration (including AMS): This includes CA administrative
costs in the following six categories, regardless of source of revenue:
• Utilization Management (UM)-those administrative functions that pertain to the
assurance of appropriate clinical service delivery. UM is intended to assure that
only eligible clients receive services, and that clients are linked to other services
when necessary. UM components include:
1) access and eligibility determination;
2) level of care determination and service/support selection; service
authorization.
3) care management if it is limited to those clients that represent a service
or financial risk to the CA and is individual case (client) monitoring
carried out on behalf of the CA.
4) utilization review of individual clients records specific to provider
practices and system trends.
5) review and monitoring of the provider network to determine appropriate
application of service guidelines and criteria.
• Customer services that encompass activities directed at the entire population of
the CA. it is understood that providers throughout the CA network carry out
some customer services activities as part of the service process; these costs are
not included in this CA administrative function, but are to be reported within the
provider costs. This function includes four types of activities:
1) information services that include general information and orientation to the CA
system; development and dissemination of informational brochures, operation
of a telephone line(s) and websites to provide information about services
provided and respond to general inquiries and outreach activities to identify
Page 4 of 8 FY2006 (August 2005)
Attachment B.3
and establish communication with underserved groups. Any marketing or
public relations activities should also be included in this category.
Additionally, CAs frequently handle various DUI information/referral and
respond to general substance abuse services inquiries. If the costs of such
activities are separately identified, these should be categorized as customer
services.
2) Coordination of client participation in services. This includes costs associated
with enhancing or enabling client participation in advisory groups, task forces,
working committees, policy and program development and other activities
intended to engage clients including other stakeholders in decision oriented
activities throughout the provider network.
3) Client complaint, grievance and appeals processes except recipient rights.
This includes activities such as investigation and management of informal
complaints and formal grievances and appeals; administrative fair hearings,
and any informal means used by the CA to resolve complaints. This also
includes costs associated with the processes used by the CA to collect data
and perform related analyses.
4) Community Benefit. This includes costs associated with activities, other than
those conducted as prevention, which are directed at the population of the
entire service areas or service area sub-populations. Examples include
participation in community planning bodies, community emergency and group
trauma services, or administrative costs associated with partnership
arrangement with community organizations.
• Provider Network Management. These costs encompass activities directed at
ensuring that qualified providers of sufficient number and variety to provide
consumer choice and that the provider network is in compliance with regulatory
requirements and the performance expectations of the CA. Provider network
management includes network development, contract management, network
policy development and provider credentialing, privileging and verification.
Network development-is the process of identifying and analyzing client provider
needs; provider procurement, development of agreements with alternative payers
or related agencies with goal of coordinating funding. Additionally, this function
incorporates network provider training in relation to the CA performance
expectations for the provider. Contract management includes contract language,
contract negotiation and oversight including reviews for evidence of abuse and/or
fraud, compliance monitoring and sanctioning as well as the development of
standards for participation in the provider panel. Costs associated with
credentialing and privileging may be included in this cost area.
Quality Management (QM): These costs encompass activities directed toward
ensuring that standards of staff, program and management performance exist;
that compliance is assessed and that ongoing improvements are introduced,
monitored and indicated improvements implemented. Since most service
provider organizations have quality management programs, CA quality
management administration is limited to specific developmental and
Page 5 of 8 FY2006 (August 2005)
Attachment B.3
improvement activities intended to improve the overall effectiveness of the CA
network's clinical and administrative practices. These could, however, include
QM pilot projects initiated and supported by the CA and intended to improve the
overall network. QM includes standard setting including activities such as
research based practice guidelines, clinical pathway protocols and authorization
criteria; selection of standard tools for screening, assessment, etc. and
performance management; Also, conducting performance assessment,
development and implementation of compliance plans and action when non-
compliance is revealed; and costs associated with managing reviews conducted
by outside agencies such as accrediting bodies, etc. Finally, this component
includes research activities; continuous quality improvement processes including
facilitation of such activities in the provider network; provider education and
training in response to QM identified needs and development of quality
improvement plans.
• Financial Management: includes costs associated with financial management
that are 1) carried out as Medicaid financial management functions delegated by
the PIHP and 2) all other financial management expenditures of the CA carried
out under its authority as the regional substance abuse coordinating agency in its
contract with MDCH/ODCP. This should not included administrative
expenditures of the CA for Medicaid administration that is not delegated by the
PIHP. Financial management includes service unit and client centered cost
analysis and rate setting or the development of standards for rates; risk-related
analysis, modeling and underwriting as well as CA expenditures relative to
provider claims adjudication and payment. This category may also include
financial management expenditures for other CA local funds.
• Information Systems Management (ISM): ISM includes the costs processes
and systems designed to support management, administrative and clinical
decisions with the provision of data and information to support accountability and
information requirements to and of the CA as a managed care provider. Costs
include equipment, software, connectivity, management, and security. ISM
administrative costs do not include those attributable to the provision of
prevention or treatment services or on behalf of a service provider.
Recipient Rights: These are the costs of CA recipient rights related responsibilities as
required by Article 6 of the Public Health Code and Administrative Rule Part 3 Recipient
Rights. Note that this excludes grievance and appeal related costs that are described
under Managed Care Administration.
Other Administrative Costs: CA administrative costs not otherwise reported, must be
included in the Other Administrative Costs category. Occasionally, a CA may serve as
a fiduciary for other grants or community services. Administrative costs associated with
these activities should be reported as Other Administrative Costs.
Page 6 of 8 FY2006 (August 2005)
Attachment B.3
HIV/AIDS EIP administrative costs may be reported under the category that is
appropriate to the internal organization of the CA and the management of the HIV/AIDS
EIP program. For example, in some CAs, this program is administered through the
prevention administration and through the treatment administration in other CAs. In the
former, these CA administration expenditures would be reported with prevention; in the
latter, with the treatment/managed care administration expenditures.
Revenue Specific CA Administration Requirements:
Medicaid
With regard to Medicaid, only those CA administrative costs for functions delegated by
the PIHP to the CA may be considered Medicaid managed care administrative costs.
All other CA Medicaid administrative costs are considered program management
costs for Medicaid purposes.
Special Note: Medicaid CA administrative costs not attributable to those functions
delegated by the PIHP to the CA must be consistent with OMB circular requirements
and should not be reported to the P1HP as managed care administrative costs. Such
costs are allowable as program administration costs. Specific reporting requirements
for Medicaid are under the authority of the PIHP.
Federal Block Grant
Federal SAPT Administration. The federal administration definition includes CA
administration expenditures for:
• Indirect costs distributed to the CA program by the administering authority (such
as a county, a county health department or a community mental health authority)
if consistent with A-87 Circular requirements
• Grants and contract management (excludes provider network related
management functions or payments for prevention and treatment services)
• Audit of the CA
• Costs associated with CA policy, program and procedure development not
specific to prevention or treatment programs.
• Personnel management/HR operations
• Legislative Liaison if applicable and otherwise allowable
These federal block grant administrative expenditures are categorized as "general
administration".
Federal Block Grant-Resource Development. Federal block grant application
requirements provide for classification and require reporting of various activities of the
substance abuse authority that they have classified as "resource development". The
CA must be able to report a reasonable estimate of direct CA administration
expenditures within the following categories:
Page 7 of 8 FY2006 (August 2005)
Attachment B.3
• Needs assessment.: This is limited to contracts/expenditures specifically for the
purposes of conducting local needs assessment(s).
• Training: CA and program including provider network staff for treatment,
prevention or administrative purposes. This is limited to CA expenditures for
training events the CA sponsors and/or directly funds. This does not include
expenditures by the provider network on training that may be included in rates or
provider payments.
• Research and Evaluation: This is with regard to effectiveness or performance
including clinical trials, program performance evaluation. This includes only
research projects designated and funded by the CA as such and excludes
routine quality assurance functions.
• Outcome/Performance Evaluation Data: Collection and/or analysis of data for
purposes of outcome and performance evaluation. This excludes costs of data
collection necessary to meet state or federal requirements or costs associated
with provider network management which includes payment for services).
• Quality Assurance: The CA must provide an estimate of the percentage of
prevention and treatment administrative expenditures that are directed toward
quality assurance functions and provide the expenditure estimate. Quality
assurance functions are defined as those specified under "Quality Management"
in this document and include site visits and program monitoring. The method by
which the CA has determined this estimate must be described in the report.
Special note: Review of resource development reporting requirements is ongoing. If
federal reporting requirements change, this reporting requirement will be removed.
MI CHILD, ABW Waiver
Administration expenditures charged to MI Child and ABW must comply with OMB
Circular A-87 or A-122 as applicable and contract requirements.
PA 2
Informal opinion by the Attorney General is that CA Administrative costs may not be
charged to PA 2 funds.
Page 8 of 8 FY2006 (August 2005)
Date
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 Oakland County Health Division Central Cost Allocation Plan was developed
(Agency Name)
consistent with OMB Circular A-87 cost principles. (A-87 can be found at:
http://www.whitehouse.cov/omb/circulars/a087/a87 2004.html)
Please check one of the following and sign below:
x 1 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.
Thomas A. Law, Chairperson, Oakland County Board of Commissioners
Name (print) Title
Revenue arid Expenditures Report Form instructions (Sept. 2004) (Word) Page 2 of 8
Attachment B
Revenues and Expenditures Report Form Completion Instructions
Michigan Department of Community Health
Office of Drug Control Policy
Fiscal Year 2006
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. All expenditures and revenues (including
Medicaid, Adult Benefits Waiver [ABM, MI 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 Certificate of Cost Allocation Plan (next page) whenever a central
cost allocation is introduced or is revised, or every two years, whichever is
sooner. This Certificate of Cost Allocation Plan form is available electronically (in
WORD) from the ODCP contract manager.
Revenue and Expenditures Report Form Instructions FY 2006 (Rev. 08/29/05) Page 1 of 14
Attachment B
(Printed On Agency Letterhead)
Certificate of Cost Allocation Plan
This is to certify that I have reviewed the Cost Allocation Plan and to the best of my
knowledge and belief:
(1) All costs included in this proposal to establish cost allocations or billings for
October 1, 2005 through September 30. 2005 are allowable in accordance with
the requirements of OMB Circular A 87, "Cost Principles for State, Local, and
Indian Tribal Governments", and the Federal award(s) to which they apply.
Unallowable costs have been adjusted for in allocating costs as indicated in the
Cost Allocation Plan. (A-87 can be found at:
httl://www.whitehouse.Qov/ornb/cjrculars/aQ87/a87 2004.html)
(2) All costs included in this proposal are properly allocable to Federal awards on the
basis of a beneficial or causal relationship between the expenses incurred and
the awards to which they are allocated in accordance with applicable
requirements. Further, the same costs that have been treated as indirect costs
have not been claimed as direct costs. Similar types of costs have been
accounted for consistently.
I declare that the foregoing is true and correct.
Agency Name:
Signature:
Name of Official:
Title:
Date of Execution:
This Certificate of Cost Allocation Plan should be used for certification of the Agency's
Cost Allocation Plan. This form must be signed by the Executive Director or Finance
Director of the agency.
Revenue and Expenditures Report Form Instructions FY 2006 (Rev. 08/29/05) Page 2 of 14
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. Please note that the fourth quarter RER
form, which would be due October 31, is not required. Final annual RER
reports will still 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 X. Distribution.
Expenditure targets for selected program areas, such as Women's Specialty
Services, will also be provided by MDCH/ODCP in the agency's initial fiscal year
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).
BUDGET AMENDMENTS
A. Definition
A budget amendment could be either an increase or decrease to the
agency's State Agreement, (Section A of RER).
A budget amendment would also be required if there is either an increase
or decrease to the agency's Total Agreement amount, as listed on the first
page of the agency's contract and on its RER. Please note that any
appreciable increase in the agency's Total Agreement amount should be
included in the agency's final contract amendment request. The Total
Agreement amount includes ALL OTHER funding sources; i.e, Medicaid,
ABW, MIChild, Fees/Collections, and Other Contracts and Sources.
B. Criteria for Approving Budget Amendments
The following provides some parameters of a budget amendment to the
agency's contract with MDCH:
• All agencies that receive State Disability Assistance (SDA) funds
and anticipate not using all of this funding, must notify
MDCH/ODCP by May 1, per its current MDCH contract. This
information should be included in the agency's final budget
amendment request.
• An agency that anticipates not meeting its Women's Specialty
target amount (per its current fiscal year allocation letter), must
notify MDCH/ODCP by May 1, per its current MDCH contract. This
Revenue and Expenditures Report Form Instructions FY 2006 (Rev. 08/29/05) Page 3 of 14
Attachment B
information should be included in the agency's final budget
amendment request.
C. Due Date for Budget Amendments
Requests for budget amendments must be submitted in writing to the
agency's contract manager not later than the due date for final
amendments to this contract. This date is typically in late June annually.
ODCP will notify the agency of a specific date at least 30 days in advance
of the due date.
IR. BUDGET REVISIONS
A. Definition
A budget revision involves moving state-administered funds between
expenditure budgets (Prevention, Treatment, HIV/AIDS, etc.)
B. Criteria for Approving Budget Revisions—Section A
Revisions in planned (budgeted) expenditures of Section A funds must
be approved in advance, in writing by the ODCP Bureau Director.
Revisions must be incorporated into subsequent quarterly RERs. The
following describes the parameters of a budget revision to the agency's
contract with MDCH:
The Department must allocate and manage state-administered funds in a
way that assures compliance with all federal and state requirements,
including SAPT Block Grant expenditure requirements. The initial
allocations for each fiscal year are in compliance with these requirements.
Nonetheless, an agency may propose to increase or reduce its allocations
for HIV/AIDS EIP/Training or for Prevention, within the limits of its total
allocation. Though there is no separate allocation for Treatment, this
flexibility applies to Treatment as well. The Department will be receptive to
approving revisions in initial allocations when 1) the agency can
demonstrate that all applicable planning and contract requirements can be
achieved, perhaps through the use of other available resources, for all
affected program and budget areas and 2) the Department can maintain
compliance with federal and state requirements. With regard to
redirection of Treatment funds, the agency must be able to demonstrate
that treatment needs within the catchment area are fully met and that
there is adequate capacity to meet drug court and offender re-entry
initiatives as well.
Revenue and Expenditures Report Form Instructions FY 2006 (Rev. 08/29/05) Page 4 of 14
Attachment B
C. Criteria for Approving Budget Revisions—Sections B-G
Revisions in planned (budgeted) revenues and expenditures of funds in
Sections B-G must be reported on quarterly RERs as revisions are
identified, and not later than the final annual report, subject to applicable
requirements in the agency's contract.
D. Due Date for Budget Revisions
The final annual due date to request budget revisions for Sections A-G is
twenty (20) days after the end of the contract period, that is, October 20
for annual contracts.
IV. INITIAL OR CURRENT ANNUAL BUDGET PLAN AND AGGREGATE
PLANNED (BUDGETED) EXPENDITURES
For State Agreement fund sources (Section A, Rows 1-4), planned (budgeted)
expenditures (pages 3 and 4 of the RER form), added together, must equal the
Initial Annual Budget Plan (Column 2) or the Current Annual Budget Plan
(Column 3), as applicable, as entered on the RER-Composite, Page 2.
For most other fund sources (Sections B-G), planned (budgeted) expenditures
are estimates. In some cases, the agency may not be planning to expend all
fiscal year revenues. It is not necessary that aggregate planned (budgeted)
expenditures (pages 3 and 4 of the RER form) equal the Initial Annual Budget
Plan or the Current Annual Budget, as applicable, as entered on the RER-
Composite, Page 2. That is, planned (budgeted) expenditures in each row do
not necessarily add to the total planned budget.
On the final RER form for the fiscal year, revenues and expenditures must be
actual. It is understood that, for non-State Agreement sources, total actual
expenditures may be less than total planned (budgeted) expenditures.
Exception: Local Match.
V. REPORTING FEES AND COLLECTIONS (SECTION F)
The MDCH/agency contract requires agencies to report actual fees and
collections associated with services that the agency purchases. The final RER
for the fiscal year must report actual revenues. On quarterly RERs, revenue
estimates may be entered.
Some agencies reimburse providers net of co-pay amounts, whether or not the
co-pays are actually collected by providers. Please do not report uncollected co-
pay revenues. Report only the revenues actually earned.
Revenue and Expenditures Report Form Instructions FY 2006 (Rev. 08/29(05) Page 5 of 14
Attachment B
Food stamp revenue, in conjunction with residency, should be reported in Fees
and Collections—Section F.
VI. LOCAL MATCH—HOW TO BUDGET FEES/COLLECTIONS AND LOCAL
FUNDS
Amounts for Local Match are reported in Sections E and F of the RER. Please
be sure that the amounts entered in Sections E and F meet Local Match criteria.
The substance abuse services contract (Attachment A) clarifies which fees and
collections may count toward Local Match.
Some agencies may be using an incorrect formula to compute the minimum,
required Local Match. Please use the following worksheet to assist in computing
the agency's Local Match percentage:
MATCH COMPUTATION - MUST BE AT LEAST 10%
a. GRAND TOTAL FUNDING
(Last row of RER, page 2, Revenues Column)
b. LESS:
Section B. Medicaid subtotal
Section C. ABW subtotal
Section D. MIChild subtotal
Section G. Other Contracts & Sources (incl. direct Federal) $
c. TOTAL (Subtotal of b.) ($
d. FUNDS SUBJECT TO MATCH (a-c)
e. MATCH FUNDS:
Section E. Local Subtotal
Section F. Fees & Collections Subtotal
f. TOTAL MATCH FUNDS (Subtotal of e.)
g. MATCH PERCENTAGE (f/d * 100 = 00.00%)
VII. MICHILD AND ABW SAVINGS
MiChild and ABW savings become Local funds in the fiscal year following the
year in which the savings were earned. Savings should be entered in Section E.
Local, Row E-Other Local.
VIII. POSTING MEDICAID REVENUES THAT ARE TRANSFERS FROM A P1HP
Some agencies receive increased Medicaid revenues in the form of transfers
from a PIHP, usually late in the fiscal year. Assuming these are current year
PEPM funds, these revenues and associated expenditures should be entered on
Revenue and Expenditures Report Form Instructions FY 2006 (Rev. 08/29/05) Page 6 of 14
Attachment B
the RER-Composite, Page 2 in Section B. Medicaid, Row 1, at the next RER
submission.
IX. ADULT BENEFITS WAIVER
For the Federal share of ABW PEPM revenue, please enter the amount on the
RER—Composite, Page 2, in Section C. ABW row. Also enter the same amount
on the RER, Page 4, under the ABW Column, Column 4 (Planned), Section C.
ABW row, assuming your agency plans to spend the full amount during the fiscal
year. This will eliminate double-counting the General Fund match for ABW
revenue.
Note that the check received by each agency each month for ABW is the Federal
share only.
For the State share of the ABW PEPM revenue, please enter the amount on the
RER, Page 4, under the ABW Column, Column 4 (Planned) Section A.1.
Community Grant row.
To obtain the State share of the ABW PEPM, use the following formula:
Federal PEPM = Total x State % = State Match
Federal %
For those agencies that plan to spend Community Grant funds over and above
the combined Federal and State shares of the ABW PEPM revenue, also include
that amount on the RER, Page 4, under the ABW Column, Column 4 (Planned),
Section Al. Community Grant row.
The Federal and State ABW percentages for each fiscal year will be provided to
the agencies by ODCP/Substance Abuse Contract Management Section, For FY
2006, the Federal percentage is 69.61% and the State percentage is 30.39%.
For all other revenues and expenditures utilized for the ABW program, over and
above the combined Federal and State shares of the ABW PEPM revenue,
please enter those amounts on the RER, Page 4, under the ABW Column–
Planned & YTD. Please note that Medicaid cannot be utilized for the ABW
program.
MDCH wants to capture the data that reports the total revenue (source and
amount) used to subsidize the ABW program.
X. DISTRIBUTION
The original and two (2) copies of the RER form should be prepared and
distributed as follows:
Revenue and Expenditures Report Form Instructions FY 2006 (Rev. 08/29/05) Page 7 of 14
Attachment B
Original - Michigan Department of Community Health
Bureau of Finance/Accounting Division
Expenditure Operations Section
P.O. Box 30720
Lansing, MI 48909-8220
One Copy - Retained by agency.
One Copy - Submitted by e-mail to:
Michigan Department of Community Health
Office of Drug Control Policy
Denise Murray
E-mail: murravdenmichigan.gov
X. RETENTION
This report should be retained for a period complying with the retention policies
established in the contract.
XII. FORM PREPARATION
An RER form instruction example (Exhibit A), an RER form completed example
(Exhibit 3), and an RER form blank example (Exhibit C) are attached for
reference.
Revenue and Expenditures Report Form/face Page--Page 1
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, if known.
I. Amendment No. — Enter the Amendment Number of the MDCH Contract
Number, if applicable.
J. Submission Type — Check one of the six (6) boxes, identifying the period
covered by the RER form.
K. Quarterly Reconciliation — For Section A only, enter the Total
Prepayments YTD and Total Expenditures YTD for State-administered
funds
Re../F_Inue and Expenditures Report Form Instructions FY 2006 (Rev. 08129105) Page 8 of 14
Attachment B
Certification Section:
This Certification Section must be signed by an authorized official certifying that
the Women's Specialty Services expenditures for the fiscal year are reported
accurately and 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.
L. Authorized Signature – Enter the signature of the official authorized to
sign the RER form.
M. Date – Enter the date of the authorized signature.
N. Title – Enter the title of the official authorized to sign the RER form.
a Contact Person – Enter the name of the person to whom questions
should be directed concerning the RER form.
P. Telephone Number and E-mail Address – Enter the telephone number
and e-mail address of the Contact Person,
Revenue and Expenditures Report Form-Composite—Page 2
A. Contractor Name and Address – Enter the name and address of the
agency.
B. Budget Period – Enter the inclusive dates of the budget period.
C. Contract/Amendment number/Submission Type – Enter the contract
number (if assigned); Amendment number (if applicable); and Submission
Type (same as on Face Page).
Revenues (Columns 2 and 3)
D. 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.
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.
P,,,?Ver:(16 and Expenditures Report Form Instructions FY 2006 (Rev. 06129/05) Page 9 of 14
Attachment B
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 a Budget and expenditure requirements for Local
Match remain in effect.
•
If changes are entered in Column 3, Sections B-G, the amounts posted in
Section A must be carried over into Column 3, even though those
amounts did not change. When totaled, Column 3 will reflect the TOTAL
Current Annual Budget Plan for the current quarter and/or final RER.
Expenditures (Columns 4-5)
F. Current Quarter—Column 4
For each row in Sections A through G, enter the current quarter
expenditures for each fund source in Column 1.
G. 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 fisted on Pages
3 and 4, under each "YTD/Final" column heading.
Balance (Column 6)
H. 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. Note that the two "Other' columns on Page 4 are not to be utilized by an
agency, unless the agency receives prior approval from its contract manager.
Revenue and Expendltures Report Form Instructons FY 2006 (Rev. 08/29/05) Page 10 of 14
Attachment B
I. Contractor Name and Address – Enter the name and address of the
agency.
J. Budget Period -- Enter the inclusive dates of the budget period.
K. Contract/Amendment number/Submission Type – Enter the contract
number (if assigned); Amendment number (if applicable); and Submission
Type (same as on Face Page).
Expenditure Detail--Planned (Columns 2 (L), 4 (N), 6 (P), and 8(R))
For each row in Section A, enter the planned (budgeted) expenditures for each
fund source (Column 1) for the current fiscal year. These expenditures are for
Administration, Treatment, Prevention and Women's Specialty. Other program
expenditure areas are listed on Page 4. These planned (budgeted) 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,
Enter SDA planned (budgeted) expenditures under the Treatment
Column/Column 4/Row A.2.
Enter SIG and Methamphetamine planned (budgeted) expenditures under the
Prevention Column/Column 6/Row A.3 and A.4, respectively.
For each row in Sections B through G, enter the planned (budgeted)
expenditures of each fund source (Column 1) for the current fiscal year.
Women's Specialty Services and Medicaid funds
The State share of Medicaid funds can be applied toward your agency's
Women's Specialty Services spending target. The spending target is listed in the
agency's initial, current fiscal year allocation letter. Both women who are served
and the services provided must meet SAPT Block Grant requirements for
women's specialty services. Contact your contract manager with any questions.
Enter Women's Specialty Services planned (budgeted) expenditures for the
Federal and State shares of the current year Medicaid PEPM under Section B.
Medicaid, Women's Specialty Column/Column 8, Rows la and lb, respectively.
For FY 2006, the State share of Medicaid is .4341%.
Expenditure Detail—YTD/Final (Columns 3 (M), 5 (0), 7 (CI), and 9 (S))
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.
Enter SDA year-to-date expenditures under the Treatment Column/Column
5/Row A.2.
Revenue and Expenditures Report Form Instructions FY 2006 (Rev. 08/29/05) Page 11 of 14
Attachment B
Enter SIG and Methamphetamine year-to-date expenditures under the
Prevention Column/Column 7/Row A.3 and A.4, respectively.
Enter Women's Specialty Services year-to-date expenditures for the Federal and
State shares of the current year Medicaid PEPM under Section B. Medicaid,
Women's Specialty Column/Column 9/Rows 1a and lb, respectively. For FY
2006, the State share of Medicaid is .4341%.
The agency is required to certify its reported expenditures for Women's Specialty
Services for the fiscal year. This certification is located in the Certification
Section of the Face Page of the RER.
Revenue and Expenditures Report Form—Page 4
T. Contractor Name and Address – Enter the name and address of the
agency.
U. Budget Period -- Enter the inclusive dates of the budget period.
V. Contract/Amendment number/Submission Type – Enter the contract
number (if assigned); Amendment number (if applicable); and Submission
Type (same as on Face Page).
Expenditure Detail--Planned (Columns 2 (W), 4 (Y), 6 (AA) and 8 (CC))
For each row in Section A, enter the planned (budgeted) expenditures for each
fund source (Column 1) for the current fiscal year. These expenditures are for
HIV EIP/Training, ABW, and two columns entitled Other. Note that the two
"Other" Columns are not to be utilized, unless the agency receives prior approval
from its contract manager. These planned expenditures must be the same as any
specific allocations or spending targets stated in the agency's initial fiscal year
allocation letter, 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 fiscal year.
Expenditure Detail—YTD/Final (Columns 3 (X), 5 (Z), 7 (BB) and 9 (DD))
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,
ABW, and two columns entitled Other. Note that the two "Other" Columns are
not to be utilized, unless the agency receives prior approval from its contract
manager.
For all rows, expenditures reported on Pages 3 and 4 must equal expenditures
reported in Column 5, Page 2.
Revenue and Expenditures Report Form Instructions FY 2006 (Rev. 08/29/05) Page 12 of 14
Attachment B
Program Bud get Composite
Attachment B.1 is a Program Budget Summary form (DCH-0385E). This form is
required by MDCH. The agency's contract manager will complete this form and
include it in the executed contract to be returned to the agency.
Revenue and Expenditures Report Form Instructions FY 2006 (Rev. 08/29/05) Page 13 of 14
Attachment B
Revenue and Expenditures Report Form
FINAL REPORTING
Fiscal Year 2006
Please note that the fourth quarter RER form, which would be due October 31, is
not required.
The final RER report is due by December 15; that is, by seventy-six (76) days after the
end of the contract period. The form must be marked "FINAL BUDGET" 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 RERs 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 by 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 contract period.
• Encumbrances - Commitments at the end of the contract 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:
Michigan Department of Management and Budget
• Guide to State Government (1210.27).
• Year-End Closing Guide.
Federal OMB Circular A-102 (Revised & DHHS Common Rule).
Revenue and Expenditures Report Form Instructions FY 2006 (Rev. 08129/05) Page 14 of 14
Attachment B
Face Page
Revenues and Expenditures Report Form
Michigan Department of Community Health
Office of Drug Control Policy
Contractor Name Federal ID No. Date Prepared
/ /
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 C Original Amendment No. (enter number)
0 Amendment
0 Initial Budget C October-December 0 January-March Submission Type (check one):
El April-June D July-September 0 Final Budget
Quarterly Reconciliation
(For State-Administered Funds Only Section A)
Total Prepayments YTD: $0
Total Expenditures YTD: $0 .,
Balance: so_
CERTIFICATION SECTION
CERTIFICATION: I certify that the Women's Specialty Services expenditures for the fiscal year are reported accurately, as entered
on Page 3, Column 9.
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 F orm FY 2006 (rev. 08/29/051) Page 1 of 4
I. #: Contract #: IAmd.
)(Mures I
Budget Period
Submission Type: To: !Submission Type:
Expenditures
Contractor Name:
From: Address:
Rues
Current Quarter (4) I Year-to-Date (5) Balance (6)
so so so
SO so
MDCH/ODCP REVENUES AND EXPENDITURES REPORT FORM-COMPOSITE
Funds Source (Column 1) I Initial Annual Budget Plan I Current Annual Budge
121 I Plan(3)
A. State Agreement
1. Community Grant
2. SDA
3. SIG
4. Methamphetamine
'.'Acctg... Use Only
A. Subtotal
B. Medicaid
1. Current Year PEPM (Federal & State
a. Federal share only for Women's
Specialty
b. State share only for Women's
Specialty
2. Reinvestment Savings
B. Subtotal
t. ABW Current Year PEPM--Federal
Share Only (Subtotal)
MI/CurrentITCWI ear PEPM
(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
$0
$0
Revenues/Expenditures Report Form Pt' 2006 (rev. 08/2905)
Contractor Name: Budget Period Contract #: lAmd. #:
EXPENDITURE DETAIL
Funds Source (Column 1)
A. State Agreement
1. Community Grant
2. SDA
3. SIG
4. Methamphetamine
"Acctg..Use Only-
YTD/Finaf (9)
ii
A. Subtotal
B. Medicaid
1. Current Year PEPM (Federal & State)
a. Federal share only for Women's Specialty
b. State share only for Women's Specialty
2. Reinvestment Savings
B. Subtotal
t. ABW Current Year PEPM—Federal Share
Only (Subtotal)
0. MlChild Current Year PEPM (Subtotal)
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
E. Subtotal
F. Fees & Collections (Subtotal)
$0 $0
$0
$01 $0 $01 $0
G. Other Contracts & Sources (Subtotal)
Grand Total of Subtotals A-G $01 $0 $01 $0
Revenues/Expenditures Report F orm FY 2006 (rev. 08/29/05) A
To: From:
$0 $0
$0 $0
$0 $0 $0 $0
$0 $0 $0 $0
$0 $0 $0 $0
$0 $0 $0 $0
Submission Type: Address:
Women's Specialty Prevention Treatment Administration
Planned (2) I YTD/f Final (3) YTD/Final (5) 1 Planned (6) YTD/Final (7) 1 Planned (8) Planned (4)
MDCH/ODCP REVENUES AND EXPENDITURES REPORT FORM
Amd. #: Budget Period
To: From:
Contract #:
Submission Type:
Contractor Name:
Address:
Other Other ABW EXPENDITURE DETAIL HIV EiPiTraining
Planned (2) YTD/Final (5) Planned (4) YTD/Final (3)
I. $0 $0 $0 $0 $0 $0 $0 1.2J
$ $ o $0 $0 $ o $0 $0
$ o $0 $0 $0 $0 $01 $011 $0 E. Subtotal
$0 $0 $0 $0 $0
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
Grand Total of Subtotals A-G $01 $01 $01
MDCH/ODCP REVENUES AND EXPENDITURES REPORT FORM
=DI
Funds Source (Column 1) Planned (6) I YTD/Final (7) Planned (8) 1 YTD/Final (9)
77;7 A. State Agreement
1. Community Grant
2. SDA
3. SIG
4. Methamphetamine
"Acctg. Use Only"
A. Subtotal
B. Medicaid
1, Current Year PEPM (Federal & State)
2. Reinvestment Savings
B. Subtotal
ABW Current Year PEPNI-Federai Share
Only (Subtotal)
D. MIChild Current Year PEPM (Subtotal)
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
Revenues/Expenditures Report r orm FY 2006 (rev. 08/29/05)
Exhibit A
Face Page
Revenues and Expenditures Report Form
Michigan Department of Community
Office of Drug Control Policy
Contractor Name Federal ID No. Date Prepared
A D
Budget Period Page Number(s) I
Mailing Address (Number and Street) FROM: 1 of 4
Contract Agreement (check one)
Contract No. (enter number) B TO:
H
City State ZIP Code G Original F Amendment No. (enter number)
C C C 0 Amendment I
L1 Initial Budget
Submission Type (check one): J E October-December E January-March
I: April-June E July-September 0 Final Budget
Quarterly Reconciliation
(For State Administered Funds Only Section A)
Total Prepayments YTD: $0
Total Expenditures YTD: K $0
Balance: $0
CERTIFICATION SECTION
CERTIFICATION: I certify that the Women's Specialty Services expenditures for the fiscal year are reported accurately, as entered
on Page 3, Column 9. .
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 bate Title
L M N
Contact Person Telephone Number and E-mail Address
0 P°
Revenues/Expenditures Report F orm FY 2006 (rev. 08129/051) Page 1 o14
Amd. #:
From:
Contract #:
Submission Type:
Contractor Name:
Address:
Budget Period
To:
$0 $01 $0 Grand Total of Subtotals A-G
Funds Source (Column 1) Initial Annual Budget Plan
,(2)
Current Annual Budget
Plan (3) Current Quarter (4) Year-to-Date (5) Balance (6)
A. State Agreement
1. Community Grant
2. SDA
3. SIG
4. Methamphetamine
"Acrtg. Use Only"
A. Subtotal $0 $0 $0 $0
B. Medicaid
1. Current Year FEPM (Federal & State)
a. Federal share only for Women's
Specialty
b. State share only for Women's
Specialty
2. Reinvestment Savings
B. Subtotal $0 $0 $0 $0
C. ABW Current Year PEPM--Federal
Share Only (Subtotal)
. MICtuld Current Year PEPM
(Subtotal)
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
E. Subtotal $0 $0 $0 $0 $0
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
sol $0
Expenditures Revenues
Revenues/Expenditures Report Form FY 2006 (rev. 08129'05) Page 2 o14
MDCH/ODCP REVENUES AND EXPENDITURES REPORT FORM-COMPOSITE
Contractor Name:
Address: ---j3From:
Contract #: K Amd. #: Bwjget Period
To: Submission Tvoe: Submission Type:
EXPENDITURE DETAIL Administration Treatment Prevention Women's Specialty
Funds Source (Column 1) Planned (2) YTD/Finat (3) Planned (4) '(TO/Final (5) Planned (6) '(TD/Final (7) Planned (8) '(TO/Final (9)
2. SDA
3. SIG
4. Methamphetamine
"Acdtg . Use Only'
$0 $0 $0 $0 $0
$0 $0 $0 $0 $0 $0 $0 $0
$01 $0 $011 $0 $0 $0 $0 $0
Grand Total of Subtotals A-G $01 $0 $01 $0 $0 $0 $0 $01
MDCH/ODCP REVENUES AND EXPENDITURES REPORT FORM
A. State Agreement
1. Community Grant
A. Subtotal
B. Medicaid
1. Current Year PEPIVI (Federal & State)
a. Federal share only for Women's Specialty
b. State share only for Women's Specialty
2. Reinvestment Savings
B. Subtotal
C. ABW Current Year PEPg--Federal Share
Only (Subtotal)
D. MIChild Current Year PEPM (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 F orm FY 2006 (rev. 08/29/05) Page 3 of 4
Contractor Name:
Address:
Budget Period
From: Ii Fro:
Contract #:
Submission Type:
Amid. #:
Other Other ABW EXPENDITURE DETAIL HIV ElPfTraining
Planned (2) YTD/Final (3) Planned (6) YTD/Final (7) Planned (8) YTD/Final (9) Funds Source (Column 1) Planned (4) I YTD/Final (5)
A. State Agreement
1. Community Grant
2. SDA
3. SIG
4. Methamphetamine
"ACctg..Use oniy".• •
A. Subtotal
B. Medicaid
$0 $0 $0 $0
$0 $0 $0 $0 $0 $0
$0 $0 $0 $0 $0 $0 $01 $0 E. Subtotal
$0 $0 sI $0 pI Grand Total of Subtotals A-G $011 $0
MDCH/ODCP REVENUES AND EXPENDITURES REPORT FORM
1. Current Year PEPM
2. Reinvestment Savings
B. Subtotal
C. ABW Current Year PEPM-Federal Share
Only (Subtotal)
D. MIChild Current Year PEPM (Subtotal)
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtotal)
Revenues/Expenditures Report F orm FY 2006 (rev. 08/29/05) Page 4 of 4
Exhibit B
Face Page
Revenues and Expenditures Report Form
Michigan Department of Community Health
Office of Drug Control Policy
Contractor Name Federal ID No. Date Prepared
38-5551234 / I ABC Substance Abuse Services, Inc. Budget Period Page Number(s)
Mailing Address (Number and Street) FROM: 10/01/05 1 of 4
320 S. Michigan Avenue TO: 09/30/06 Contract No. (enter number)
Contract Agreement (check one)
City State ZIP Code 2 Original Amendment No. (enter number)
Any Town mi 40000 0 Amendment
a Initial Budget 0 October-December CI January-March Submission Type (check one):
ClApril-June El July-September CI Final Budget
• - - ---- - - - — .
_ _
To
Total I
Balance: $0
CERTIFICATION SECTION
CERTIFICATION: I certify that the Women's Specialty Services expenditures for the fiscal year are reported accurately, as entered
on Page 3, Column 9.
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 FY 2006 (rev. 08/29/05D Page 1 of 4
Amd. #: Contractor Name: ABC Substance Abuse Services, Inc. Budget Period
To: 09/30/06 From: 10/01/05
RovenueS
(Contract #:
Submission Type: Initial Budget
Lxpen ;tures 1
Address: 320 S. Michigan Avenue, Any Town, MI 40000
Current Quarter (4) Year-to-Date (5)
$2,967,805
$870,639
$76,396
$58,604
$42,900
$1,048,539
$70,000
$6,500
$505,616
$234,902
$8,000
$748,518
$7,000
$240,000
$5,088,362
$O $0
$0 $0
$0 $0
$0
$70,000
$6,500
$5056161
$234,902
$8,000
$748,518
$7,000
$240,000
$5,088,362
$0
MDCWODCP REVENUES AND EXPENDITURES REPORT FORM-COMPOSITE
Funds Source (Column 1)
A. State Agreement
1. Community Grant
2. SDA
3. SIG
4. Methamahetamine
"Acctg. Uee Only" „
Initial Annual Budget Plan Current Annual Budget Plan(3) (2)
$2,549,962
$206,258
$71,500
Balance (6)
$2,549,962
$206,258
$140,085
$71,500
S2,967,8051 SO
. Current Year PEPM (Federal & State) I $870,639
a. Federal share only for Women's
Specialty $76,396
b. State share only for Women's
Specialty $58,604
2. Reinvestment Savings I $42,900
$1,048,5391 $0
C. ABW Current Year PEPM—Federal
Share Only (Subtotal)
U. MICtuld Current Year PEPM
(Subtotal)
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
E. Subtotal
F. Fees & Collections (Subtotal)
G. Other Contracts & Sources (Subtota;)
Grand Total of Subtotals A-G
A. Subtotal
B. Medicaid
B. Subtotal
Revenues/Expenditures Report Form FY 2006 (rev, 08(29/05) Page 2 of 4
EXPENDITURE DETAIL Administration Treatment Prevention Women's Specialty
Planned (4) Planned (6) Planned (8) YTD/Final (7) YTD/Final (5) YID/Final (9)
3. SIG
4. Methamphetamine
$140,085
$71,500
"!Acctg: Use Only"-
so $0 $0
1. Community Grant $260,000 $1,240,103 $802,659 $147,000
2. SDA $206,258
A. Subtotal $260,000 $1,446.361 $1,014,244 $147,000
$174,128 1. Current Year PEPM (Federal & State)
a. Federal share only for Women's Specialty
b. State share only for Women's Specialty
2. Reinvestment Savings
$696,511
$76,396
$58,604
$42,900
$0 $0 $0 $135,000 $174,128 $739,411 $0 $0
6,500
$252,808 $252,808
$58,725
$2,500
$176,177
$5,500
E. Subtotal $2,5001 $0 $428,985 $317,033 $0 $0 $0 $0
F. Fees & Collections (Subtotal) $5,000
G. Other Contracts & Sources (Subtotal) $120,000
$0 Grand Total of Subtotals A-G $2,746,257 $282,000 $0 $436,6281 $0
$120,000
$1,331,2771 $120,000
MDCH/ODCP REVENUES AND EXPENDITURES REPORT FORM
Contractor Name: ABC Substance Abuse Services, Inc. Budget Period Contract #: Amd. #:
Address: 320 S. Michigan Avenue, Any Town, MI 40000 From:10/01/05 To:09130106 Submission Type: Initial Budget
Funds Source (Column 1) Planned (2) YTD/Final (3)
A. State Agreement
B. Medicaid
B. Subtotal
C. ABW Current Year PEPM—Federal Share
Only (Subtotal)
D. MIChild Current Year PEPM (Subtotal)
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
Revenues/Expenditures Report F orm FY 2006 (rev. 08129105) Page 3 of 4
Amd #: Contract #:
Submission Type: Initial Budget
Other Ot ner
Planned (8) YTD/Final (9) Planned (6) YTD/Final (7)
$0 $0 $0 $0
$0
Grand Total of Subtotals A-G $102,200 $01 $70,000 0
MDCH/ODCP REVENUES AND EXPENDITURES REPORT FORM
Contractor Name: ABC Substance Abuse Services, Inc. I Budget Period
Address: 320 S. Michigan Avenue, Any Town, MI 40000 IFrom:10101105
EXPENDITURE DETAIL I HIV ElPfTraining
To:09130106
ABW
Funds Source (Column 1) I Planned (2)
A. State Agreement
1. Community Grant • I $100,200
2. SDA
3. SIG
4. Methamphetamine
7Acctg., Use Only.
YID/Final (3) I Planned (4) I YID/Final (5)
A. Subtotal I $100,200
B. Medicaid
1. Current Year PEPM
2. Reinvestment Savings
B. Subtotal
C. ABW Current Year PEPM-Fecieral Share I
Only (Subtotal) I $70,000
D. MIChild Current Year PEPM (Subtotal)
E. LOCAL
1. Current Year PA2
2. PA2 Fund Balance
3. Other Local
E. Subtotal I $0
F. Fees & Collections (Subtotal) I $2,000
G. Other Contracts & Sources (Subtotal)
Revenues/Expenditures Report F arm FY 2006 (rev. 08/29/05) Page 4 of 4
ATTACHMENT C
REQUIRED REPORTS
ATTACHMENT C
REQUIRED REPORTS—Fiscal Year (FY) 2006
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 previously issued Action Plan
Guidelines (APG). Revisions in the "Required Reports" table, which were made since
prior editions, are shown 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 6 (August 2005)
Attachment C
Required Reports—Fiscal Year (FY) 2006
Document Title/Data Period Due Date Instructions &
Submissions Covered S•ecifications
Administration Expenditures Fiscal Year December 15, 2005— Per 8/15/05 e-mail
Report 2005 Voluntary submission to CAs from M.
(SACM) Steinberg
Fiscal Year December 15, 2006— Contract
2006 Mandatory submission Attachment B
(SACM)
Audit Report Fiscal Year 9 months after close of Contract, Part II
Contractor's fiscal year
(Office of Audit) ...
Communicable Diseases (CA Annual January 31—for previous As outlined in APG
TB, Hepatitis, STD Services Plan fiscal year. (SACM) FY 2005/2006,
and HIV EIP Plan) issued December
2004, Page 16.
Health Insurance Portability & As services Last day of following month, Contract
Accountability Act (HIPAA) 837 are provided, submitted via DEG to Attachment F--
Encounters records are MDCH/M1S-Operations Instructions for
completed. Treatment Episode
Submissions Data Set (TEDS)
are all monthly Submission for
records for Substance Abuse
each quarter. Services
Coordinating
Agencies (August
2005)
HIV Data Report-- CA assures Monthly HIV Data submitted via Contract
HIV providers will utilize web-based system in real Attachment A
MDCH/HAP1S data collection time at www.hapis.orq
methods, including Uniform
Reporting System (URS)
CareWare for case
management and HIV Event
System (HES) for Counseling,
Testing and Referral (CTR) and
other prevention/risk reduction
activity.
Injecting Drug Users 90% Monthly Last day of thc month FY 2004 AAPC
Capacity Trc\atment Report and felfewir4g4h-e-r-epaFt-ffieFith7
Federal Priority Populatiena Submit via U.S. mail
Waiting List Certification Report (SACM).
"REVISED IN FISCAL YEAR
2006'
See report entitled, "Waiting
List Exceptions Report".
Page 2 of 6 (August 2005)
Attachment C
Required Reports—Fiscal Year (FY) 2006
Document Title/Data Period Due Date Instructions &
Submissions Covered Specifications
Methamphetamine Grant Quarterly or PIRE Cross-Site Per 4112/05 e-mail
Narrative Report semi-annually Evaluation Report due by from Annemarie
NOTE: Applies only to agencies according to the 15th day of the month Hodges.
with allocations for this program. project year. following the end of a
quarter. (January 15, April
15, July 15, and October
15)
(e-mail copy to SACM)
Narrative Report for Per 7112/05 e-mail
ODCP due as follows: from Brenda
March 15, 2006 for the Stoneburner, with
period covering 10/1/05- attached report
2/28106. Second Annual form to be used.
Report (Project Year 2)
also due on March 15,
2006. Semiannual report
due October 15, 2006 for
period covering 3/1106-
9/30/06.
(e-mail copy to SACM)
Non Synar Tobacco Retailers Meet* Last day of the month Prevention Section
Inspections Report : : -: -- -::- -:- - wiN-e-Riai-i
'DISCONTINUED IN FISCAL iRstr-bietien-s-aftel--fefFn
YEAR 2006** to CAs.
See report entitled, "Youth
Access to Tobacco Activity
Report".
Notice of Excess or Insufficient Fiscal Year May 1 (SACM) Contract
Funds Attachment A
Payables Report Fiscal Year September 2006 Contract
(BFA/Accounting) Attachment B
Determined by DMB at
year-end closing
Performance Indicators Quarterly (Oct- 60 days following the end Contract
Nov; Jan- of the quarter: March 1, Attachment F--
March; April- June 1, September 1, and Performance
June; July- December 1. (SACM) Indicators for
Sept.) Substance Abuse
Services: Electronic
Submission Forms
(Revised July 2005)
Page 3 of 6 (August 2005)
Attachment C
Required Reports—Fiscal Year (FY) 2006
,
Document Title/Data Period Due Date Instructions &
Submissions Covered Specifications
Prevention -Expenditures Report 1 Fiscal Year January 31 for prior fiscal FY 2002 AAPG,
'REVISED IN FISCAL YEAR y ar (SACM) Revision, dated
2006 06/28/01
See report entitled, "Prevention
Expenditures by Strategy
Report". _ _
Prevention Expenditures by Fiscal Year January 31—for prior Contract
Strategy Report fiscal year (SACM) Attachment F (As
outlined in APG FY
200512006, issued
December 2004,
_ Page 40.)
Prevention Services Annual January 31—for prior Contract
Population Report fiscal year (SACM) Attachment F
Revenues and Expenditures Quarterly (Oct- Last day of the month, Contract
Report (RER) Form Quarterly Nov; Jan- following the end of the Attachment B
NOTE: The 4th quarter RER March; April- quarter: January 31, April
form is not required to be June) 30, and July 31.
submitted. (BFA/Accounting)
(e-mail copy: SACM)
Revenues and Expenditures Fiscal Year December 15, 2005 Contract
Report (RER) Form–Final 2005 (BFA/Accounting) Attachment B
(e-mail copy: SACM)
Fiscal Year December 15, 2006 Contract
2006 (BFA/Accounting) Attachment B
(e-mail copy: SACM)
Sentinel Events Data Report Semi-Annual Last day of the month Contract
(residential treatment only) CA Summary following the end of the 2' Attachment F-
& 4t April 30 and Sentinel Event
October 31 (SACM) Reporting
Guidance (August
2005)
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 Sena-i-aFifilia-1 April 30 and October 31 F-Y--2004,4ARG
'DISCONTINUED IN FISCAL (SACM)
YEAR 2006'
See report entitled, "Youth
Access to Tobacco Activity
Report".
Page 4 of 6 (August 2005)
Attachment C
Required Reports—Fiscal Year (FY) 2006
Document Title/Data Period Due Date Instructions &
Submissions Covered Specifications 1
Tobacco Retailer Listing-- Annual March 31 (SACM) Contract
Improved Attachment A
Tobacco Vendor Education Annual July 31 (SACM) Contract Attachment
Activity Report A
**DISCONTINUED IN FISCAL
YEAR 2006'
See report entitled, "Youth
Access to Tobacco Activity
Report".
Treatment admission and Monthly Last day of each month, Contract
treatment discharge records data submitted via DEC to Attachment F--
upload (QI) MDCH/MIS-Operations Instructions for
Treatment Episode
Data Set (TEDS)
Submission for
Substance Abuse
Services
Coordinating
Agencies (August
_ 2005)
Waiting List Exceptions Report Monthly End of each month in Contract
which exceptions occur. Attachment F
(SACM)
Women & Families Progreso Semi Annual April 30 and October 31 Per August 24, 2001
Narrative Report and Annual, (SACM) c mail with
'REVISED IN FISCAL YEAR respectively attachment.
2006' ,
See report entitled, 'Women's
Specialty Services Report".
Women's Specialty Services Annual January 31—for prior Contract
Report fiscal year. (SACM) Attachment F
Youth Access to Tobacco Annual January 31—for prior Contract
Activity Report fiscal year. (SACM) Attachment F
,
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
Page 5 of 6 (August 2005)
Attachment C
Required Reports—Fiscal Year (FY) 2006
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:\4823 4823@dchbull
For discharges: put c:14824 4824(dchbull
Office of Audit reports should be sent to:
Overnight services (UPS, Fed. Ex.)--
Michigan Department of Community Health
Office of Audit
Quality Assurance and Review Section
P.O. Box 30479
Lansing, MI 48909-7979
U.S. mail--
Michigan Department of Community Health
Office of Audit
Quality Assurance and Review Section
Capitol Commons Center
400 S. Pine Street
Lansing, MI 48933
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
E-mail to: murraydenmichigan.gov
Page 6 of 6 (August 2005)
ATTACHMENT D
REVENUES AND EXPENDITURES REPORT
FORM/ INSTRUCTIONS
AND
EQUIPMENT INVENTORY SCHEDULE
(See Attachment B)
ATTACHMENT E
AUDIT STATUS NOTIFICATION LETTER
ATTACHMENT E
AUDIT STATUS NOTIFICATION LETTER
(Required for subrecipient Contactors claiming exemption from audit submission
requirements)
Please fill in the following information, sign after the statement below and mail this form
to: Michigan Department of Community Health, Office of Audit, Quality Assurance and
Review Section, P.O. Box 30479, Lansing, MI 48909-7979 or fax it to: (517) 338-5443.
Form is due to the Department within nine months after the end of the Contractor's
fiscal year. Please do not submit this form with your signed agreement.
Agency Name:
Address:
Federal ID Number:
For Agency's Fiscal Year Ended (month/date/year):
Agency Contact Person (Name, Title, Phone #):
The purpose of this letter is to comply with Michigan Department of Community Health
(MDCH) grant contract audit requirements. I certify that the agency listed above
expended less than $500,000 in federal awards from all funding sources, and expended
less than $500,000 total MDCH funding. I also certify that our agency's financial
statement audit did not include any disclosures related to current or prior years that
could negatively impact MDCH-funded programs. Therefore, we are not required to
submit either a Single Audit or Financial Statement Audit to MDCH.
Signature
Print Name/Title
Date
ATTACHMENT F
OTHER REQUIREMENTS
I. DATA REQUIREMENTS
Data Collection/Recording and Reporting Requirements—(Revised August
2005)--Effective October 1, 2005
Instructions for Treatment Episode Data Set (TEDS) Submission for Substance
Abuse Services Coordinating Agencies--Revised August 2005
Performance Indicators for Substance Abuse Services: Electronic Submission
Forms--Revised July 2005
Sentinel Event Reporting Guidance—Revised August 2005
II. LOCAL ADVISORY COUNCIL GUIDELINES—August 9,1990
III. METHADONE REQUIREMENTS
Methadone, Reporting of Nonprescription—March 21, 1996
Treatment Policy-03, Buprenorphine--September 1, 2004 (Revised August 10,
2005)
Treatment Policy-04, Off-site Dosing of Opioid Treatment Medication-
Methadone—effective March 1, 2005
Treatment Policy-05, Enrollment Criteria for Methadone Maintenance and
Detoxification Program—September 1, 2003; Revised August 2005—effective
October 1, 2005
IV. REPORTING REQUIREMENTS
Prevention Expenditures by Strategy Report—August 2005
Prevention Services Population Report—August 2005
Waiting List Exceptions Report—August 2005
Women's Specialty Services Report—August 2005
Youth Access to Tobacco Activity Report—August 2005
Page 1 of 2 FY 2006 (August 2005)
V. TREATMENT REQUIREMENTS
Access Management System (AMS) Requirements DRAFT—December 2004
Individualized Treatment Planning—September 2003
Treatment Policy-02, Acupuncture--May 1, 1994 (Revised 2001)
Page 2 of 2 FY 2006 (August 2005)
ATTACHMENT F
I. DATA REQUIREMENTS
Data Collection/Recording and Reporting Requirements (Revised
August 2005)—Effective October 1, 2005
Instructions for Treatment Episode Data Set (TEDS) Submission for
Substance Abuse Services Coordinating Agencies (Revised August
2005)
Performance Indicators for Substance Abuse Services: Electronic
Submission Forms (Revised July 2005)
Sentinel Event Reporting Guidance—(Revised August 2005)
FY 2006 (August 2005)
MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
OFFICE OF DRUG CONTROL POLICY
DATA COLLECTION/RECORDING AND REPORTING
REQUIREMENTS - Effective 10/1/2005
Overview of Reporting Requirements
The reporting of substance abuse services data by the CA as described in this material
meets several purposes at MDCH including:
-Federal data reporting for the SAPT Block Grant application and progress report, as
well as for the treatment episode data set (TEDS) reported to the federal Office of
Applied Studies, SAMHSA.
-Managed Care Contract Management
-System Performance Improvement
-Statewide Planning
-CMS Reporting
-Actuarial activities
Special reports or development of additional reporting requirements beyond the initial
data and reports required by the Department may be requested within the established
parameters of the contract. The CA will likely maintain, for management and local
decision-making, additional information to that specified in the reporting requirements.
Standards for collecting and reporting data continue to evolve. Where standards and
data definitions exist, it is expected that each CA will meet those standards and use the
definitions in order to assure uniform reporting across the state. Likewise, it is
imperative that the CA employs quality control measures to check the integrity of the
data before it is submitted to MDCH. Error reports generated by MDCH will be
available to the submitting CA the day following a DEG submission. MDCH's
expectation is that the records that receive error Ids will be corrected and resubmitted
as soon as possible. The records in the error file are cumulative and will remain errors
until they have been corrected.
Individual services recipient data received at MDCH are kept confidential and is always
reported out in aggregate. Only a limited number of MDCH staff can access the data
that contains any possible individual client identifiers. (Social Security number, date of
birth, diagnosis, etc.) All persons with such data access have signed assurances with
MDCH indicating that they are knowledgeable about substance abuse services
confidentiality regulations and agree to adhere to these and other departmental
safeguards and protections for data.
Page 1 of 7 July 2005
DATA COLLECTION/RECORDING AND REPORTING REQUIREMENTS (Continued)
Technical specifications-- including file formats, error descriptions, edit/error criteria,
and explanatory materials on record submission with associated record tagging
requirements at the CA level to assure data synchronization with MDCH data records,
are in the Supplemental Instructions for 837 Encounter and Quality Improvement (QI)
Data Submission for Substance Abuse Coordinating Agencies. This document is on
the MDCH Website at:
http://www.michigan.gov/documents/SA_SupplementallnstructionsforEncounters_0218
03_58382_7, pdf
Reporting covered by these specifications includes the following:
-Treatment Admission Records (due monthly)
-Treatment Discharge Records (due monthly)
- 837 4010 Encounter Records for Non-Medicaid Clients (due monthly)
-Performance Indicators Reports (due quarterly)
-Sentinel Events (due semi-annually)
A. Basis of Data Reporting
The basis for data reporting policies for Michigan substance abuse services
includes:
1, Federal funding awarded to Michigan through the Substance Abuse
Prevention and Treatment (SAPT) federal block grant to share in support
of substance abuse treatment and prevention requires submission of
proposed budgets and plans. Resources and plans must be reviewed
and considered by the State in light of statewide needs for substance
abuse services.
2. Public Act 368 of 1978, as amended, requires that the department
develop:
A comprehensive State plan through the use of federal, State, local, and
private resources of adequate services and facilities for the prevention
and control of substance abuse and diagnosis, treatment, and
rehabilitation of individuals who are substance abusers.
In addition, the department shall:
Establish a statewide information system for the collection of statistics,
management data, and other information required.
Collect, analyze and disseminate data concerning substance abuse
treatment and rehabilitation services and prevention services.
Page 2 of 7 July 2005
DATA COLLECTION/RECORDING AND REPORTING REQUIREMENTS (Continued)
Conduct and provide grant-in-aid funds to conduct research on the
incidence, prevalence, causes, and treatment of substance abuse and
disseminate this information to the public and to substance abuse
services professionals.
3. Comprehensive planning requires statewide needs assessments to
include identification of the extent and characteristics of both risks for
development and current substance abuse problems for the citizens of
Michigan.
B. Policies and Requirements Regarding Data
Treatment Data reporting will encompass Substance Abuse (SA) services
provided to clients supported in whole or in part with state administered funds
through MDCH/DCS/SA contracted funds and funds for SA services to Medicaid
recipients included in CMHSP contracts. Prevention services data requirements
are addressed in Minimum Data Set (MDS) instructions.
Definitions:
State administered funds: Any state or federal funding provided by the MDCH/DCS/SA
contract. Funds provided include federal SAPT Block Grant, state general funds,
MIChild, and other categorical or special funds. Since funds provided under the
contract include local match (fees and collections, local, and P.A. 2 as examples) data
reporting requirements include those funds which are considered as "in-part" funding.
Medicaid funds are covered under the MDCH/CMHSP contract as required reporting by
CAs as part of their data reporting responsibilities.
Data: Client admission and discharge records (for treatment services), and client
institutional and professional encounter records, and backup required to produce this
information (e.g. billings from providers, services logs, etc.). Prevention services data
are not addressed herein.
Services: Substance abuse treatment (residential, residential detox, intensive
outpatient, outpatient, including pharmacological supports as part of above), substance
abuse assessment (screening, assessment, referral and follow-up) provided by
appropriately state licensed programs. Prevention services data are not addressed
herein.
Supported in whole or in part: Those services for which the CA pays, inclusive of co-
pays with other sources of funds (e.g. first party, third party insurance, other funding
sources).
Policy:
Reporting is required for all clients whose services are paid in whole or in part with state
administered funds regardless of the type of co-pay or shared funding arrangement
Page 3 of 7 July 2005
DATA COLLECTION/RECORDING AND REPORTING REQUIREMENTS (Continued)
made for the services. This includes both co-pay arrangements where public funds are
applied from the starting date of admission to a service, as well as those where public
funds are applied subsequent to the application of other funding or payments.
For purposes of MDCH reporting, an admission is defined as the formal acceptance of
a client into substance abuse treatment. An admission has occurred if and only lithe
client begins treatment. Therefore, events such as initial screening, assessment, and
referral are considered to take place before an admission and should be reported under
the SARF record.
A client is defined as a person who has been admitted for treatment of his/her own drug
problem. A co-dependent (a person with no alcohol or drug abuse problem who is
seeking services because of problems arising from his or her relationship with an
alcohol or drug user) who has been formally admitted to a treatment unit and who has
his/her own client record also should be reported with the record indicating his/her co-
dependency.
For purposes of identifying the circumstances under which data should be submitted,
MDCH assumes a simplified process model of treatment services delivery related to
substance abuse. Basic to this model is the treatment episode, which is defined the
period of service between the beginning of a treatment service for a drug or alcohol
problem and the termination of services for the prescribed treatment plan. The first
event in this episode is an admission and the last event is a discharge.
Any change in service and/or provider during a treatment episode should be reported
as a discharge, with transfer given as the reason for discharge. For reporting purposes,
"completion of treatment" is defined as the completion of ALL planned treatment for the
current episode. Completion of treatment at one level of care or with one provider is
not "completion of treatment" if there is additional treatment planned or expected as
part of the current episode. The reason for discharge given in all instances where the
treatment has not been terminated should be 06 (Transfer-Continuing in Treatment).
The code of 06 will identify the fact that the client's treatment episode did not terminate
on the date reported.
1. Data definitions, coding and instructions issued by MDCH apply as written.
Where a conflict or difference exists between MDCH definitions and information
developed by the CA or locally contracted data system consultants, the MDCH
definitions are to be used.
2. All data collected and recorded on admission and discharge forms shall be
reported using the proper Michigan Department of Consumer and Industry
Services (MDCIS) substance abuse services site license number. MDCIS
license numbers are the only basis for recording and reporting data to MDCH at
the program level.
Combined reporting of client data in data uploads from more than one license
site number is not acceptable or allowable, regardless of how a CA funds a
provider organization.
Page 4 of 7 July 2005
DATA COLLECTION/RECORDING AND REPORTING REQUIREMENTS (Continued)
3. Failure to assure initial set up and maintenance of the proper site license number
and CA code will result in data that will be treated as errors by MDCH. Any data
submitted to MDCH with improper license numbers will be rejected in full. The
necessary corrections and data resubmissions will be the sole responsibility of
the CA in cooperation with the involved service providers.
4. Each admitted or served client shall have both his/her Social Security Number
(SSN) and a unique CA Client ID as required individual client numbers.
Along with the SSN, there must be a unique CA client identifier assigned and
reported. It can be up to 11 characters in length, all numeric. This same number
is to be used to report data for all admissions and encounters for the individual
within the CA. It is recommended that a method be established by the CA and
funded programs to ensure that each individual is assigned the same
identification number regardless of how many times he/she enters services in
any program in the region, and that the client number be assigned to only one
individual.
5. CAs will send Medicaid encounters to the respective PIHP that is responsible for
the Medicaid funding and will not send them to MDCH. CAs will send
encounters into MDCH only for Community Grant clients. If Block Grant funds
pay for room and board for a Medicaid client, then the encounter sent in must
reflect only that portion of the encounter. This requirement does require that the
CA split out Medicaid encounters from all others and to send those only to the
PIHP.
6. Any changes or corrections made at the CA on forms or records submitted by
the program must be made on the corresponding forms and appropriate records
maintained by the program. Failure to maintain corresponding data at the CA
and program levels will result in data audit exceptions on discovery of
discrepancies during an MDCH on-site data audit/review. Each CA and its
programs shall establish a process for making necessary edits and corrections to
ensure identical records. The CA is responsible for making sure records at the
state level are also corrected via submission of change records in data uploads.
7. Providers of residential and/or detoxification services must maintain a daily
client census log that contains a listing of each individual client in treatment. This
listing can be made in client name or using the client identification number.
Census must be taken at approximately the same time each day, such as when
residents are expected to be in bed. MDCH or the CA will review the daily client
census logs in data auditing site visits.
Providers of pharmacologic support services (either methadone or LAAM) must
maintain a log that contains a listing of each client in treatment, and their daily
dosages of these medications provided by the program. MDCH or the CA will
review these logs in data auditing site visits
Page 5 of 7 July 2005
DATA COLLECTION/RECORDING AND REPORTING REQUIREMENTS (Continued)
8. Diagnosis coding on client data forms shall be consistent with the client's
substance abuse treatment plan. If there is more than one substance abuse
diagnosis determined, then the secondary diagnosis code should be reported
accordingly. Diagnosis codes on the data records must be consistent with those
listed on other client documentation (such as billing forms, etc.). Codes should
be entered using only the proper DSM-IV definitions for substance abuse and
other related problems that are being treated.
The primary diagnosis should correspond to the primary substance of abuse
reported at admission. The secondary diagnosis may or may not be consistent
with the secondary substance of abuse if another diagnosis better reflects a
more serious secondary problem than the secondary substance.
9. CAs are to provide training, manuals, and records/ forms to their funded services
providers.
10. CAs must make corrections to all records that are submitted but fail to pass the
error checking routine. All records that receive an error code are placed in an
error master file and are not included in the analytical database. Unless acted
upon, they remain in the error file and are not ,removed by MDCH. If the volume
and scope of the errors becomes too burdensome, the CA can request a "service
bureau delete". This will clear out the database completely and allow the CA to
start over from an empty database.
MDCH recommends that errors should be acted upon before the subsequent
month's submissions are due. Via the established error correction process for
admissions, discharges, and encounters, the CA should strive for a 100%
acceptance rate by the time the FY is closed out in mid November. A minimum
threshold for each CA of a 98% acceptance rate for admissions and discharges
and 95% rate for encounters will be applied to the end-of year final data set. Any
CA's data with acceptance rates under these thresholds will be deemed out of
compliance for completeness of reporting.
CAs must edit and correct as necessary all data records, and ensure that
complete data entry occurs routinely as data flows into their offices and data
systems. Data shall be as current as possible. All data from a particular month
shall be entered into the CA's database by the end of the following month in
preparation for uploading to MDCH.
11. The CA is responsible for generating each month's data upload to MDCH
consistent with established protocols and procedures. Monthly and quarterly data
uploads must be received by MDCH via the DEC no later than the last day of the
following month.
12. The CA should not request MDCH to provide reimbursements for any program
that does not submit complete and accurate data to the CA within the
established reporting time lines. Late or incomplete data reporting by the
Page 6 of 7 July 2005
DATA COLLECTION/RECORDING AND REPORTING REQUIREMENTS (Continued)
provider and/or CA may result in the withholding and potential loss of funding
from MDCH.
13. Treatment clients may not be admitted to more than one program or one service
category at the same time. The only allowable exceptions are: (1) for case
management services from a CDR for clients who are also open at a treatment
program; and (2) for clients receiving methadone in one program while receiving
other specialized treatment in another.
14. The CA must communicate data collection, recording and reporting requirements
to local providers as part of the contractual documentation. CAs may not add to
or modify any of the above to conflict with or substantively affect State policy and
expectations as contained herein.
15. This document contains several references to data entry, editing, and correction
by the CA. These references are not meant to preclude the program from data
entry, editing, and correction. MDCH encourages data entry at the program level
as long as all the criteria for reporting content and editing are met.
16. Statements of MDCH policy, clarifications, modifications, or additional
requirements may be necessary and warranted. Documentation shall be
forwarded accordingly.
17. Treatment clients who have not had any treatment activity in a 30-day period
shall be considered inactive and their case discharged. A treatment discharge
record should be completed and submitted; the effective date of discharge would
be the last date of actual contact with the program. The record should be
completed and submitted based on the clients status as of the last contact;
records with all data items marked as unknown or left blank are not acceptable.
Page 7 of 7 July 2005
FISCAL NOTE (MISC. 105265) November 10, 2005
BY: FINANCE COMMITTEE, CHUCK MOSS, CHAIRPERSON
IN RE: DEPARTMENT OF HEALTH AND HUMAN SERVICES/HEALTH DIVISION - 2005/2006
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) $4,640,745 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. Grant acceptance represents a decrease from the prior year grant
amount of ($14,171) a (.03%) decrease from the previous year.
4. The grant period extends from October 1, 2005 through
September 30, 2006.
5. The Fiscal Year 2006 budget should be amended as delineated below.
FY2006
FY2006 FY2006 Amended
Adopted Adjustment Budget
Fund 28249
Project - GR203
Budget Reference - 2006
Revenue
1060261-28249-134790-615571 State $4,654,916 ($14,171) $4,640,745
Expense
Dept. Fund Program Acct.
1060261-28249-134790-730373 Cont. Sys. 271,674 48,243 319,917
1060261-28249-133950-730373 Cont. Svs. 242,302 (2,804) 239,498
1060261-28249-133950-730373 Cont. Svs. 70,000 (70,000) 0
1060261-28249-134790-730373 Cont. Sys. 4,070,940 10,390 4,081,330
$4,654,916 ($14,171) $4,640,745
FINANCE COMMITTEE
/Lo_s/-
FINANCE COMMITTEE
Motion carried unanimously on a roll call vote with Melton and
Jamian absent.
Resolution #05265 November 10, 2005
Moved by Moss supported by Coleman the resolutions on the Consent Agenda, as amended, be adopted (with
accompanying reports being accepted).
AYES: Coleman, Coulter, Crawford, Douglas, Gershenson, Gregory, Hatchett, Jamian, KowaII, Long,
Melton, Middleton, Molnar, Moss, Nash, Palmer, Patterson, Potter, Rogers, Scott, Suarez, Wilson,
Woodward, Zack, Bullard. (25)
NAYS: None. (0)
A sufficient majority having voted in favor, the resolutions on the Consent Agenda, as amended, were adopted
(with accompanying reports being accepted).
I elf APPROVE THE MONO MOWN
5 -----
STATE OF MICHIGAN)
COUNTY OF OAKLAND)
I, Ruth Johnson, 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 10, 2005, with the original record thereof now remaining in my office.
In Testimony Whereof, I have hereunto set my hand and affixed the seal of the County of Oakland at
Pontiac, Michigan this 10th day of November, 2005.
Ruth John on, County Clerk