Missouri Department of Health & Senior Services

Proposal for Contract

ADULT DAY HEALTH CARE PROGRAM
Thank you for your interest in the Adult Day Health Care (ADHC) program. This program is intended to provide funding for ADHC authorized clients during periods of Medicaid ineligibility also known as spenddown.

FUNDING SOURCE

• Services are funded through Social Services Block Grant/General Revenue (SSBG/GR) with the Department of Health and Senior Services during periods of Medicaid ineligibility.

PRE-APPROVAL REQUIREMENTS
The following requirements must be met prior to submission of a proposal:

1. Entities must have an Adult Day Care (ADC) license in good standing issued by the Department of Health and Senior Services, Section for Long Term Care Regulation pursuant to 19 CSR 30-90.010 and 19 CSR 30-90.020. If the ADC is not currently licensed, an Application for License is available on the department's website.
2. Entities must have a Medicaid participation agreement with the Department of Social Services, MO HealthNet Division (MHD) pursuant to 13 CSR 70-92.010. MHD can be contacted regarding MO HealthNet enrollment by e-mail at providerenrollment@dss.mo.gov.

PROCESS OF REVIEW AND APPROVAL
Upon receipt of a proposal, the Department:

• will process the proposal and determine the ADC's eligibility for a contract. The Department will conduct any investigation necessary to verify, supplement or change the information contained within the proposal.
• If the proposal is incomplete or further informationis needed from the applicant to verify or supplement the proposal, the Department will request the information in writing.
• When the review is complete, and if the ADC is found to be in good standing, a Participation Agreement for Home and Community Based Care for Adult Day Health Care (contract) will be mailed to the applicant for completion. The Agreement will not become effective until the Department's Director of Division of Administration signs it.
• Once the contract has been fully executed by the Department, the ADC will receive a copy of the fully executed contract and written notification of their SSBG/GR provider number.
• Upon receipt of the SSBG/GR provider number, the ADC can begin providing services to authorized clients of the Department during periods of Medicaid ineligibility.

ADDITIONAL ASSISTANCE
Should you require additional information or have questions regarding the proposal, you must contact the HCS Provider Contracts Unit by e-mail at ihscontracts@dhss.mo.gov. Submitting questions through e-mail will create less interruptions for staff that are reviewing proposals and will provide a written record of the Department's response. Your e-mail must include the name of your agency.

PROPOSAL SUBMISSION
All items listed in the Proposal Outline must be included in the proposal and must be organized according to the outline. All information must be submitted to:
    Department of Health and Senior Services
    HCS Provider Contracts Unit
    920 Wildwood Dr.
    P.O. Box 570
    Jefferson City, MO 65102-0570
The physical address is 912 Wildwood Dr. This address should only be used if hand delivering the proposal. The 920 Wildwood Dr. address must be used for sending the proposal overnight delivery. Hand delivered proposals must be left with the receptionist. No receipts will be provided unless a pre-prepared receipt is brought with the proposal. The receptionist will then date stamp the receipt.

Prior to submission of the proposal,

• make a photocopy of the proposal for your records;
• review the Proposal Checklist to ensure all information is included; and
• all information is in the same order as the Proposal Outline.

A cover letter that is on the ADCs letterhead and signed by an authorized representative of the ADC. The cover letter must include:

• statement indicating whether any persons, individuals or business entities identified within the proposal are currently contracted with the Division of Senior and Disability Services to provide any other service. If so, list the type of service and the name of the company;
• statement indicating whether any persons, individuals or business entities identified within the proposal have ever previously contracted with the Department, and, if so, the name of the company and the position held; and
• statement indicating whether any persons, individuals, or business entities identified within the proposal have ever been sanctioned, suspended, terminated from participation, or denied enrollment in Medicaid, Medicare, SSBG/GR, or any other government public assistance program.

SECTION I – PROVIDER PROFILE
Document the following information on the Provider Profile form:

1. SSBG/GR Number it if has been assigned. If a number has not been assigned, leave the field blank.
2. Full legal name of Provider as filed with the Missouri Secretary of State, Internal Revenue Service and Missouri Department of Revenue.
3. Physical Address, City, State and Zip Code
4. Mailing Address, if different than the physical address, City, State and Zip Code
5. Telephone Number
6. Fax Number
7. E-Mail Address
8. Federal Employer Identification Number (FEIN)
9. Medicaid Adult Day Health Care Provider Number
10. Adult Day Care License Number
11. Counties for which transportation will be provided
12. Name of the on-site manager or contact person
13. Name of the Registered Nurse
14. Registered Nurse';s license number

SECTION II – BUSINESS ORGANIZATION
The ADC's correct legal name must be the same on all of the following documents and must be used through the proposal.

1. Business Organizational Structure form:

• fill in the ADC's correct legal name on the first page;
• complete only one section of the form;
• submit the required documents as indicated on the form according to the section of the form completed; and
• sign the bottom of page two of the form.

2. A copy of the Federal Employer Identification Number (FEIN) notification from the Internal Revenue Service.
3. Notification from the Department of Revenue (DOR) of the Missouri Employer Identification Number.
4. Vendor registration verification e-mail. Register as a vendor with the State of Missouri through the Missouri Office of Administration at https://www.moolb.mo.gov/Glue/default.asp. The Standard Registration (no fee) is required. The Premium Registration ($50 annual fee) is not required. If the name and federal employer identification number are already registered, do not submit anything.
5. A current Vendor No Tax Due certificate issued by the Missouri Department of Revenue. Information regarding this certificate is available at http://www.dor.mo.gov/tax/business/sales/hb600.htm, Obtaining a Vendor No Tax Due.
6. A copy of the ADC license issued by the Section for Long Term Care Regulation.
7. A copy of the notification letter from MHD of the ADHC Medicaid enrollment.

SECTION III - ASSURANCES

1. Assurance the main phone line will be answered by clearly identifying the ADC by name.
2. Assurance to use the Change Request form to notify the Department of changes in the exact street address, telephone number or business hours, including the timeframe.
3. Assurance to maintain internet access and an e-mail address at all times in order to retrieve information posted on the Department website and to communicate with the Department.
4. Assurance to maintain subscription to DSDS E-News.
5. Assurance to comply with all applicable federal and state laws including laws authorizing or governing the use of federal funds paid to the ADC through the adult day health care program.
6. Assurance to comply with the Fair Labor Standards Act as amended, Title VII of the Civil Rights Act of 1991 as amended, the Americans with Disabilities Act of 1990, and all other applicable federal and state laws, regulations and executive orders regarding employment practices.
7. Assurance to comply with all applicable rules and laws administered by the Occupational Safety and Health Administration.
8. Assurance to comply with all applicable Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations and all amendments thereafter.
9. Assurance to enroll and comply with all requirements of the E-Verify federal work authorization program. Information regarding E-Verify is available at http://www.dhs.gov/files/programs/gc_1185221678150.shtm.